SEED Madagascar Community Development (Pioneer) Application
v May 2016
Community Development Volunteer / Internship Programme Application Form
We require extensive information, including health disclosures, to assess your suitability for our programmes.Please answer all questions fully. It will take approximately 20-30 minutes to complete.

The Community Development Programme is offered as an internship for those wishing to gain experience and credit for a college or university course, through mentorship and self-evaluation. Please indicate if you would like to intern with us.

We do not pass on your private information to any other person or organisation not directly associated with SEED Madagascar management. We may refer to the SEED Madagascar team doctor for a confidential medical opinion.

We may also use this information to contact your friends and/or family in an emergency. By completing this form you are giving us your permission to use the information that you provide for the purposes mentioned above.

General Information
1. Family Name (Last Name, as it appears on your passport) : *
Your answer
2. First Name (Other Names, as appears on your passport) : *
Your answer
3.Occupation : *
Your answer
If a student, please provide name of University :
Your answer
University Course subject:
Your answer
4. Date of Birth : *
MM
/
DD
/
YYYY
5. Male or Female : *
6. Nationality (eg British/American/Spanish) : *
Your answer
7. Permanent Address: *
Your answer
8. Day time telephone number (please include international codes) : *
Your answer
9. Evening telephone number (please include international codes) : *
Your answer
10. E-mail address : *
Your answer
11. Do you have any additional needs?
Including disabilities or learning difficulties :
Your answer
Community Development Programme Placement Dates
You can join this programme for a minimum of 4 weeks up to the full 10 week programme. Community Development runs 4 times each year commencing the first week in January, April, July & October. We prefer volunteers to join at the beginning of the programme however on occasion we can flex for you to join mid-term but you may be required to contribute an additional fee toward hire of a 4x4 vehicle to transport you to join the team out in the bush.Only those volunteers opting for the full 10 week placement will experience the full range of activities offered on the programme.
12.(i) Please indicate your first preference for start month from the drop down box below *
12.(ii) Please indicate your first preference for start year from the drop down box below *
12.(iii) Please indicate your second preference for start month from the drop down box below *
12.(iv) Please indicate your second preference for start year from the drop down box below *
13. Please indicate your preferred placement duration *
4
5
6
7
8
9
10
No. of weeks
14. Have you ever applied to us before for a volunteer placement? *
15. Please provide a short summary of your employment history & qualifications *
Your answer
16. Explain as fully as possible why you are applying for this placement. *
Your answer
17. How do you feel you will benefit from the Community Development programme? What do you expect to gain from it? *
Your answer
18. What particular education/relevant experience do you have that will be useful during the placement? *
Your answer
19. Please list any practical skills that you have and beside each please indicate whether you have (a.) basic ability, (b.) good practical ability or (c.) could train others in that skill. (e.g. plant identification, farming, etc.) *
Your answer
20. Please list any teaching skills that you have and give details. *
Your answer
21. Do you speak another language? *
If yes please give detail of language and profficiency
Your answer
22. Is there any work that you would not be prepared to do? *
If yes, please give more information.
Your answer
23.How will you raise your minimum donation ? *
Please refer to the website for costs - https://madagascar.co.uk/volunteer/pioneer/costs
Your answer
24. May we share a personal introductory summary about yourself & your contact email with your fellow volunteers prior to departure? *
25. If so, please write a personal introduction:
Your answer
Criminal Convictions
Criminal convictions can have a bearing on your ability to obtain a visa. Please note that the Rehabilitation Act of 1974 (Exceptions) Order 1975 (as amended) states that you do not generally have to disclose details of spent convictions.

Please note we will request you to undertake a DBS Criminal Background Check if accepted onto the Community Development Programme. For British citizens we will process either a Basic or Enhanced check depending on the volunteer programme, and for volunteers of other nationalities we will request they independently carry out a police check of the equivalent level.

26. Have you been convicted of any criminal offence in the last 5 years? *
27. Do you have any criminal proceedings pending ? *
28. References
Please provide the name, address, email address & contact telephone number (include country codes) of two character witnesses who are not your relatives, one of which should know you in a professional or academic capacity.

We will contact both of these referees and your participation on this porgramme will be subject to SEED Madagascar receiving two adequate references from them.

Name - Referee 1 *
Your answer
Address Referee 1 *
Your answer
E-mail address Referee 1 *
Your answer
Phone number Referee 1 (please include international codes) : *
Your answer
Name Referee 2 *
Your answer
Address Referee 2 *
Your answer
E-mail address Referee 2 *
Your answer
Phone number Referee 2 (please include international codes) : *
Your answer
Health Information
Before filling out the following section, please read the following excerpt from the Memorandum of Understanding that you will be expected to sign to confirm your place:


Malaria is a serious problem in Madagascar and in some cases it can be life-threatening. The villages where SEED Madagascar work are pathogen-rich environments and there is potential to contract various illnesses when working in them. These villages are isolated and it may take up to 24 hours before you can receive medical attention. The regional hospital in Fort Dauphin is basic and if more complicated treatments are required it will be necessary to be evacuated. We recommend you consider these facts when deciding which immunisations to undertake or medication to bring.

By confirming my place on the Community Development Programme, I agree to follow health protection advice that I have gained from a qualified travel health professional. This will include a vaccination programme and a malarial prophylaxis regime:

The malarial prophylaxis I will take will comply with World Health Organisation guidelines. I understand that alternative or homeopathic prophylaxis regimes are unacceptable whilst I am working with SEED Madagascar in Madagascar. N.B. It is SEED Madagascar’s experience that over 40% of volunteers who choose to take Doxycycline suffer unacceptable sun-sensitivity which affects their ability to work.

All volunteers must be vaccinated against Tetanus to participate in the Community Development Programme. We also advise you to be vaccinated against Typhoid, Meningitis, Hepatitis A & B, Rabies and Polio but up to date professional advice must be sought.

Ensure that you disclose all health and medical information to your insurer to enable the correct cover to be provided for you. It is your responsibility to inform your insurance company of any pre-existing medical conditions or your insurance may be invalid.

Health Information
Please answer all the questions in question 29. For every question you answer yes to, please complete a separate copy of the SEED Madagascar Additional Health Information Form to provide details.You will be given the option to open this form at the bottom of this table.
29. Do you currently or have you ever suffered from the following ? *
Yes
No
1.1 Asthma
1.2 Tuberculosis
1.3 Any disease/ problems affecting your breathing/ ear/ nose/ throat
1.4 Hypertension (high blood pressure)
1.5 Heart disease, heart failure, rheumatic or valvular disease
1.6 Heart attacks or angina
1.7 Arrhythmia, palpitations or any disease/ problems affecting the heart
1.8 Epilepsy
1.9 Migraine
1.10 Vertigo or dizziness
1.11 Strokes, mini strokes, blackouts or any neurologicaldisease/ problems
1.12 Anaemia or other blood disorder
1.13 Diabetes, hypothyroidism or any other endocrine disease/ problems
1.14 Arthritis, rheumatism or gout
1.15 Back pain, lumbago, sciatica or neck pain
1.16 Any other joint, bone or muscle disease/ problems
1.17 Eczema or psoriasis
1.18 Hay fever
1.19 Hives, urticaria or any other disease/ problems affecting the skin
1.20 Gynaecological disorder/ problems
1.21 Emotional difficulties including depression, anxietyor panic attacks
1.22 Mental health issues
1.23 Behavioural difficulties including ADHD, hyperactivity
1.24 Any other major illnesses
1.25 Any operations
1.26 Any other conditions needing hospital, general practitioner or other care
1.27 Have you needed to attend a hospital in the last 3 years
1.28 Any allergy to any medicine
1.29 Any allergy to insect bites
1.30 Any other allergy
Did you answer yes to any of the health questions above ? (Choosing yes will open a SEED Madagascar Additional Health Information Form which we require you to complete for all medical conditions you have declared) *
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