SEED Madagascar Conservation Programme Application
v May 2016
Conservation Volunteer/ Internship Application
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 Conservation 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
10. Evening telephone number (please include international codes) :
Your answer
11. E-mail address :
Your answer
12. Do you have any additional needs?
Including disabilities or learning difficulties :
Your answer
Conservation Programme Placement Dates
Our aim is to make a lasting contribution to the conservation of biodiversity and sustainable development efforts in the Sainte Luce area. As such, the activities undertaken on the programme vary depending on the time of year and on current local requirements. For example, tree planting activities can only take place from February to June; as a result participants in the programme during this time may focus solely on tree planting. Likewise the type of research work to be carried out will be dependent on research requirements at the time. SEED Madagascar will strive at all times to ensure that volunteers enjoy a rewarding experience in Madagascar. Please feel free to contact SEED Madagascar: info@seedmadagascar.org

The 10 week programme runs 4 times a year. Please refer to the website for module dates and durations and then select below

http://madagascar.co.uk/get-involved/conservation-programme/apply-now

13. Please indicate your preferred start date.
MM
/
DD
/
YYYY
14. Please indicate your preferred placement duration.
15. Have you ever applied to us before for a volunteer placement?
16. Why you are applying for this placement?
Please explain as fully as possible indicating if you are intersted in an internship
Your answer
17. Do you have any particular education / relevant experience / practical skills that will be useful during the placement ?
Your answer
18. Is there any work that you would not be prepared to do?
If yes, please give more information.
Your answer
19. How will you raise your minimum donation ?
Your answer
20. May we share a personal introductory summary about yourself & your contact email with your fellow volunteers prior to departure?
21. If so, please write a personal introduction:
Your answer
Criminal Convictions
Criminal convictions can have a bearing on your ability to obtain a visa. The Rehabilitation Act of 1974 (Exceptions) Order 1975 (as amended) states that you do not generally have to disclose details of spent convictions. We may ask you to undertake a DBS Criminal Background Check if accepted onto the Conservation Programme.
22. Have you been convicted of any criminal offence in the last 5 years?
23. Do you have any criminal proceedings pending ?
Health Information
Before filling out the following section read this excerpt from the Memorandum of Understanding that you will have 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 Conservation 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 Conservation 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
Answer all the questions in question 24. 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.
24. 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
25. 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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