Centre for the Rehabilitation of the Paralysed (CRP) Application Form for Short Term Volunteers
Name Address
Country
Telephone Fax E-mail
Emergency Contact Person Name
Address
Age (select) 16-21 22-30 31-45 46+ Sex (select) Male Female
Details of Dependents who are traveling with you
Names Details
Details of Higher Education Details of Relevant Training
Brief Work Experience
Do you have any disability that will require assistance? Yes No
If yes, give details
Do you suffer from any medical condition you feel we should know about? Yes No
Extra curricular activities/interests/skills
Date of intended visit to CRP - From To
Have you ever been convicted in a court of law for any offence except for minor traffic violations?
Yes No
Category of Volunteering (select) General Volunteer Volunteer on Placement to CRP Professional Volunteer Research and Development Scientist
For Professional Volunteer please specify profession
Volunteer Information
Please state briefly your intended goals in volunteering to work at CRP
Name two referees with position, address and contact number (they will be contacted only at the final stage)
Name Name
Position Position
Address Address
If you would like to elaborate on any of the above categories, please do so below
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