Volunteer Application Part 1-Butler Creek Health

Name

Address

Phone Number

Email

Date of Birth

Sex

Marital Status

Do you have dependent children?

Yes

No

If yes, what are their names and ages?

Occupation

Country of Citizenship

Visa Type

Passport Number

Name on Passport

Person to notify in case of emergency

Phone Number of Emergency Contact

Are you a Seventh-day Adventist?

Yes

No

What is the name of the church you attend?

Home Church Address

When were you baptized?

Name of your Pastor

Pastor's Phone #

Pastor's Email Address

Are you familiar with the writings of Ellen G. White?

Yes

No

Which books written by Ellen G. White have you read?

Have you taken an active role in your local church? Have you been involved in community outreach? Please give a brief description below.

Do you believe that Ellen G. White received the prophetic gift?

When did you accept Christ as your personal Savior?

Are you a faithful, tithe giving church member of the organized General Conference of Seventh-day Adventist Church?

Why are you applying to be a volunteer at Butler Creek Health Education Center?

Could you briefly share about your conversion experience/testimony?

Are you new to (Medical) Missionary Work?

Yes

No

If no: What ministry or ministries have you served in?

In what capacity where you serving?

Please enter the time frame you served in the ministry/ministries mentioned above?

Have you received any training for (medical) missionary work?

Yes

No

If, yes: Where did you receive your training? What year?

List a name, email address and telephone number of a member of a ministry that we may contact for references:

List a name, email address and telephone number of another member of a ministry that we may contact for references:

How well do you understand spoken English?

Fluent

Intermediate

Beginner

Can you read and write in English?

Fluent

Intermediate

Beginner

Please give the name, email address, and telephone number of a reference who knows you well, who is not related to you, and who is not a previous employer

Please give the name, email address, and telephone number of a second reference who knows you well, who is not related to you, and who is not a previous employer

List the name, email address, and telephone number of a previous employer that we may contact for reference

List the name, email address, and telephone number of a second previous employer that we may contact for reference

Have you ever been discharged or asked to resign?

Yes

No

If yes, please explain:

Have you been convicted of a crime other than a minor traffic offence?

Yes

No

If yes, please explain:

Please summarize special skills and qualifications acquired from employment or other experience:

Have you ever smoked/vaped?

Yes

No

If yes, how many packs/day?

For how long did you smoke?

When did you quit?

Did you ever drink?

Yes

No

If yes, what was your average weekly consumption?

For how long did you drink?

When did you quit?

Have you ever taken illegal drugs?

Yes

No

If yes, what type of drug?

For how long did you do drugs?

When did you quit?

Are you a vegetarian?

Do you have food allergies or special dietary requirements?

Yes

No

If yes, please list them:

Do you do regular exercise?

Yes

No

What is your favorite exercise?

Are there any physical, mental, or medical conditions that would affect your ability to attend class and complete work assignments? If yes, please provide year of occurrence and how it might affect you currently

List major surgeries, accidents, or illnesses for which a doctor’s care was required and the year of occurrence

Volunteer Application Part 1

Personal Information

Church Affiliation

Personal Testimony

Missionary Work

General Information

Medical History