Application Form

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CONTACT DETAILS

Title: *
Given name *
Surname *
Postal address *
Town *
State * (Required if country is Australia)
Postcode *
Country *
Work phone
Home phone
Mobile
Fax
E-mail *
Preferred method of contact

PERSONAL DETAILS
Date of birth
Gender Male   Female  

ALTERNATIVE CONTACT
Name:
Relationship to you
Home number
Work number
Mobile number

PROFESSIONAL DETAILS
Please provide a brief outline of your professional work history

SKILLS
Please list any specialist skills you think may be relevant on this volunteer placement (You can also include non-work related skills, eg playing musical instrument)

EXPERIENCE AND MOTIVATION
1. Have you ever been involved in volunteer/community activities? Yes   No  
If you have answered YES, please give a brief description of the key activities, and include the organisation/group and dates:
2. Have you ever worked for or in an Aboriginal community or organisation? Yes   No  
If YES, please provide brief details:
What attracts you to the Filling the Gap program? Why do you want to be involved?

AVAILABILITY

Please list dates you would be available for volunteering in 2008. Please note:
  • We require a minimum of 5 days volunteer work to make this a viable contribution, but would prefer two weeks (or more) if possible.
  • Flights can be organised to include vacation/recreation time on either side of your time working at Wuchopperen.
  • The weather in Feb/Mar is particularly wet and there is the possibility of cyclones, in February especially.(See end of the application form for more weather details)
  • Dates should be entered as DD/MM/YYYY.
1st Preference dates: *
2nd Preference dates: *

OTHER PEOPLE ACCOMPANYING VOLUNTEER
Please list any other people who will be accompanying you. This helps us with planning your accommodation, which will be in one or two bed-roomed self contained units, close to Wuchopperen.
Person 1
Relationship to you:
Person 2
Relationship to you:
Person 3
Relationship to you:
Person 4
Relationship to you:

HELP US SPREAD THE WORD
Do you know of other dentists or health professionals who may be interested in volunteering in the Filling the Gap Program. Please list names and contact details (email preferred)

HOW DID YOU HEAR ABOUT FILLING THE GAP
 
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