Health. Space for Comments. Declaration of Consent and Signature

Health

Please let us know if there are any special circumstances (recent death of a loved one, case of illness within the family etc.) or if you suffer from any health problems (physically, psychologically, emotionally etc.), that could influence your voluntary service.

Is there anything to consider regarding your state of health? (e.g. you are unable to lift people due to back problems, special diet)

Have you been undergoing a therapy due to a physical or psychological illness within the last 12 months?

☐ no ☐ yes, if so, please give us some background information regarding your therapy:

Start – End/ Kind of therapy

Do you have to take any special medication? If so, please state and explain.

Please submit a medical certification issued by your doctor.

The medical certification states that you are physically and psychologically healthy, free from infectious diseases, resilient, and that there are no medical reservations concerning a long term voluntary service abroad.If you suffer from a pre-existing condition it should be mentioned in the medical certification.

Space for Comments

Is there anything else you would like to let us know?

Declaration of Consent and Signature

Do you agree that your email address and mobile phone will be passed on to other participants in the voluntary program.

☐ Yes ☐ No

I understand that – depending on the country I am going to – the duration of my Voluntary Service will be between 9 and 12 months.

I understand that my application will not be returned to me in case of a rejection or withdrawal, but will be disposed of.

I have completed the application myself.

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