International Volunteer Application

Personal Information

Country Applying To:

First Name

Last Name

Address

City

State

Zip Code

Country

Day Number

Evening Number

Mobile Number

Website

Date of Birth

Passport No.

Expiration Date

Place of Issue

Country of Issue

Sex

Marital Status

Full Name of Spouse

Dependents

Please list any dependents who will be living with you during your volunteer service

Dependent 1

Legal Name

Date of Birth

SS. No.

Passport No.

Dependent 2

Legal Name

Date of Birth

SS. No.

Passport No.

Dependent 3

Legal Name

Date of Birth

SS. No.

Passport No.

Dependent 4

Legal Name

Date of Birth

SS. No.

Passport No.

Health Information

Health Conditions

Please list any chronic health conditions you have and any current treatment (e.g. diabetes, heart problems, depression, physical handicap, etc.)

Do you smoke?

Is your health insurance valid outside your country?

(Valid insurance is required for all volunteers)

Name of Health Insurance Carrier

Policy No.

Address/Phone of Insurance Carrier

Emergency Contact

Name

Relationship to You

Street/P.O. Box

State

Zip Code

Country

Telephone

Foreign Languages

Please list any foreign languages that you have experience with.

Language 1

Language

Check all that apply

Read

Write

Speak

Language 2

Language

Check all that apply

Read

Write

Speak

Language 3

Language

Check all that apply

Read

Write

Speak

Other Information

Have you ever been convicted of a crime other than a traffic violation?

If yes, provide details on the charge, date of offense, and disposition of the case.

List foreign countries you have visited and length of stay

Dates of availability

Please describe the dates you are available to volunteer. For example: 6/1/2010 to 9/1/2010.

Agreement

I hereby certify that I have verified all the information given above and that it is true and correct. Should I be
accepted and placed as a volunteer with Minnesota International Health Volunteers (MIHV), I agree to abide by
MIHV's professional standards of conduct. I further understand that should I act otherwise, I will be requested to
leave the country of volunteer placement and return home immediately at my own expense.

Furthermore, I understand that there are inherent dangers in traveling and volunteering in a foreign country. I
understand that MIHV has provided emergency evacuation coverage for me and will make every effort to ensure
my safety in the case of an emergency. Given this, I hereby exempt MIHV from any liability should any harm
come to me during my volunteer service.

Furthermore, I understand that I am responsible to provide my own round-trip transportation as well as personal
expenses while volunteering with MIHV. I understand that MIHV will provide housing space for each volunteer. If
MIHV housing does not meet my housing needs, I understand that I will need to provide and pay for my own
housing during my volunteer service.

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Document Attachments

Resume

Please attach a copy of your resume. It must be in .doc, .docx, or .pdf format and no larger than 800KB.

References

Please attach a document with 3 professional references. It must be in .doc, .docx, or .pdf format and no larger than 800KB.

Photo

Please attach a photo of yourself. It must be no larger than 800KB.

Passport Pages

Please attach a copy of the signature pages of your passport. The image must be no larger than 800KB.

Professional Licensure Information

Please attach professional Licensure Information (if applicable). The file must be no larger than 800KB.

Cover Letter

Please upload a pdf of your cover letter here.

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Formerly Minnesota International Health Volunteers Improving the health of women, children and their communities around the world.

International Volunteer Application

Formerly Minnesota International Health Volunteers
Improving the health of women, children and their communities around the world.