Full Name on Passport
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Email
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Phone
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(###)
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####
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Proposed dates to volunteer (or write "pending")
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Passport Number (or write "pending")
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Date passport issued (or write "pending")
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Date passport expires (must be at least 6 months after return)
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Profession (or student/retired)
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Name of employer and contact information (or write "none")
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Church affiliation (if applicable)
Nationality (if dual)
Birthdate
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MM
DD
YYYY
Birthplace
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Father's full name (needed for VISA)
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Mother's full name (needed for VISA)
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Last 5 countries you have visited (for VISA)
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Have you ever been convicted of a felony?
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If yes, explain.
Volunteer program for which you hope to volunteer
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Bwindi Community Hospital
Batwa Development Program
Uganda Nursing School Bwindi
Specific volunteer activities you have in mind
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Describe any international travel and volunteer work . If you have ever been to Uganda or another part of East Africa, please provide the location, month and year of last trip (or write "none")
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What qualifications, experience, training, skills have prepared you to volunteer in this capacity?
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Why do you want to volunteer?
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Name of sending organization (if applicable)
Contact and address of sending organization (if applicable)
Allergies and health conditions (or type "none")
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Describe any physical limitations that might inhibit your ability to hike, walk up stairs or travel in a vehicle on poor roads (or write "none")
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Major health events within the last year (or type "none")
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Medications you take and reason for taking (or type "none")
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Blood type (if known)
Physician name and contact information
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Spouse's Name (if applicable)
Spouse's phone (if applicable)
(###)
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Spouse's email (if applicable)
Emergency contacts (name, address, phone, email)
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Reference #1 (include contact information)
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Reference #2 (include contact information)
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Reference #3 (include contact information)
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VOLUNTEER AGREEMENT, RELEASE AND WAIVER OF LIABILITY
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By submitting my application, I agree to the following conditions:
1. I will abide by Bwindi Community Hospital, Uganda Nursing School Bwindi and the Batwa Development Program volunteer rules and regulations as well as local laws.
2. I will expeditiously follow-up on all requirements for passports, visas, financial obligations, vaccinations, travel insurance, and meetings.
3. I will pay for my own expenses, including but not limited to airfare, accommodations, meals, excursions and other miscellaneous trip costs.
4. I will respect the host culture and those with whom I interact and will not try to convince them of my own viewpoint. I know that there are different ways to accomplish the same objectives and that my way is not necessarily the best.
5. I will be tolerant and respectful of all religious beliefs and understand that attendance at Christian worship and other activities is encouraged, but it not required, to build relationships and gain an appreciation of the culture.
6. I will abstain from expressing opposing political views or rules, sports, religion, race or traditions or using insensitive humor.
7. I will follow the advice given concerning local traditions, proper attire, and food and beverage safety. I will refrain from any alcoholic beverages or illegal drugs.
8. I will accept and submit to my supervisor and abide by his or her decisions.
9. I will stay in groups and not venture off on my own at any time and will not travel or walk alone at night; and I will refrain from crossing into the Democratic Republic of the Congo.
10. I understand that my work is but a tiny speck on the bigger picture that program partners are trying to accomplish and promise to not be overly demanding, offend or embarrass the local hosts and to do my best to help them attain their long-term goals.
11. I will accept difficulties that arise and understand that unexpected delays and program changes may arise.
12. I agree to serve without compensation or benefits as a direct volunteer for Bwindi Community Hospital, Uganda Nursing School Bwindi or the Batwa Development Program; I acknowledge that I am not a volunteer of the Kellermann Foundation.
13. I understand that in the event my conduct is considered so unsatisfactory as to jeopardize the success or safety of the program, and that mediation has failed to correct my behavior, I will return home at my own expense.
14. I acknowledge that I am subjecting myself to certain risks voluntarily, including and in addition to those risks that I normally face in my personal and business life, including but not limited to such things as health hazards due to poor food and water, diseases, pests and poor sanitation; potential danger from lack of control of local population; potential injury while working; and inadequate medical facilities.
15. I certify that I have read the Kellermann Foundation Volunteer Guide and allow the Kellermann Foundation to conduct screening, including a criminal background check. I intend to be legally bound by this agreement.
16. I grant and convey to the Kellermann Foundation all right, title, and interest in any and all photographic images and video or audio recordings, including but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.
I release and discharge the organizations and individuals which helped make these arrangements, including the Kellermann Foundation, Bwindi Community Hospital, Uganda Nursing School Bwindi, the Batwa Development Program, their agents, employees, officers and volunteers, from all claims, demands, actions, judgments, or executions that I have ever had, or now have, or may have, or which my heirs, executors, administrators, or assigns may have or claim to have against these organizations, their agents, employees, officers, and volunteers, and their successors or assigns, for all personal injuries, known and unknown, and injuries to property, real or personal, caused by, or arising out of this journey.
I expressly agree that this Release is intended to be as broad and inclusive as permitted by law. I agree that in the event any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release, which shall continue to be enforceable. I certify that the information I have provided and will provide is true, correct, and complete to the best of my knowledge.
In signing this agreement, I represent that I am 18 years of age or older or my parent/guardian will also sign accepting the above conditions on my behalf.
Name of person signing
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First Name
Last Name
