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VERIFIE VOLUNTEER FORM
Thanks for your interest in becoming a volunteer with Verifie
* Indicates required question
Email
*
Your email
Name
*
Your answer
Address (where do you live?)
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Your answer
Phone number
*
Your answer
Whatsapp Number (repeat if same as phone number)
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Your answer
Current occupation (choose all applicable)
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Work (full time)
Work (part time0
Study (Undergraduate)
Study (Graduate)
Study PhD
Required
Emergency Contact;
*
Your answer
Relationship to you
*
Your answer
Phone number 1 (Emergency Contact)
*
Your answer
Phone number 2 (Emergency Contact)
Your answer
Please tick any of these skill areas if they relate to you:
*
Training or education in HIV and STI’s
Experience in the health sector ie , doctor , nurse , pharmacist , psychologist , med lab , student etc.
Experience in blood letting
Experience working with people living with HIV
Experience working with counseling
Other:
Required
Please elaborate on these experiences in the space below:
*
Your answer
Languages spoken (Choose all applicable)
*
English
French
Twi
Ga
Ewe
Hausa
Other:
Required
Other voluntary work
Your answer
Hobbies / Interests
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Your answer
Where did you first hear about verifie?
*
Friend
Whatsapp Message
Whatsapp Status
Twitter
Facebook
Youtube
Instagram
At a Verifie event
Flyer
Brochure
Poster
Website
Other:
Personal Information:
Age
*
Your answer
Sex
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Female
Male
Other:
Highest education qualification achieved?
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High School Certificate
Diploma
Degree
Masters
Doctorate
Profesor
Qualifications (your educational background)
*
Your answer
Privacy statement:
The personal information on this form is being collected for the purposes of recruiting and selecting volunteers wishing to work with Verifie. The information may also be required for evaluation purposes. Any evaluation reports developed will not identify individual volunteers by name. This information may be shared with partner organisations and funding bodies.
By electronically signing this form I attest that the information supplied is true and accurate. I confirm that I am willing to volunteer with Verifie and in doing so will abide by all rules and regulations and will ensure to not engage in any activities which may cause harm or injury be it physical or psychological to colleagues and clients alike
*
Yes
No
Name:
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Your answer
Date
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MM
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YYYY
Send me a copy of my responses.
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