Volunteer Application Form (Short Term)

Volunteer Application

Basic Info

Applicant's Name *

Email Address *

Phone *

Address - Street number and Street Name *

Address - city, state and zip code *

Birthdate *

Purpose And Timing

Primary Purpose of Trip *

Secondary Purpose of Trip (if any) *

Since "Other" was chosen as a purpose, please explain here.

Proposed Time Frame For Trip (Approx. Dates & Duration) *

Second Choice Time Frame (Approx. Dates & Duration) *

Do you anticipate future similar commitments to Loma de Luz? *

Yes

Previous Similar Trips (Purpose & Approx. Dates)

Skills And Experience

What is your level of professional training? *

(e.g. 4th yr.medical student, 2nd year PA student, certified medical technologist, certified diesel mechanic, licensed/bonded master plumber, etc.)

Other skills or significant experience?

(e.g. Construction/Maintenance, Skilled Painter, Welder, Experienced Carpenter, Computer, Secretarial, Accounting/Administration, Teaching)

What is your Spanish Language proficiency? *

(fluent, conversant, functional, survival, hola) and would you require a translator (at $10 per day) to perform your duties at Hospital Loma de Luz. (This does not apply to 4th year medical students.)

Maritial Status

Single

Married

OtherOther

If your spouse and/or children will be joining you, please list their professional and educational background and their level of involvement

Personal Information

Primary motivation for volunteering

(eg, education, experience, serving God, serving humanity)

Who referred you to The Cornerstone Foundation / Hospital Loma de Luz?

Please briefly share your faith testimony *