AGENCY APPLICATION - La Société Française de Bienfaisance Mutuelle

AGENCY APPLICATION
La Société Française de Bienfaisance Mutuelle

Thank you for your interest in the International Volunteer Program. Please complete the following application and return it to our office with a brochure of your association. If you need more than one volunteer, please send us the same number of brochures at:

The International Volunteer Program
210 Post Street, Suite 502
San Francisco, CA 94108
Ph: (415) 477-3667
Fax: (415) 477-3669

AGENCY INFORMATION

Agency name: __________________________________________________________________

Name & Title of the Volunteer Supervisor/Agency Contact:

______________________________________________________________________________

Telephone Number: _____________________________ Fax: ___________________________

Agency Address: _______________________________________________________________

______________________________________________________________________________

Email Address: _________________________________________________________________

Website: ______________________________________________________________________

What is the mission of your agency? What services do you provide? What population do you serve?

______________________________________________________________________________

Please describe your agency - size, number and type of employees, atmosphere, work ethic, type of building etc.:

______________________________________________________________________________

VOLUNTEER POSITION

How many volunteers are you requesting? _______________ Gender preference ___________

Describe in detail the work/tasks the volunteers(s) will be performing. Discuss the level of client involvement, what the work environment is like. What will an average day be like?

______________________________________________________________________________

What are your expectations/ requirements for a volunteer?

______________________________________________________________________________

List any special physical requirements and skills needed for successful completion of this work:

______________________________________________________________________________

Will formal or on-the-job training be provided? ________________________________________

What type of clothing is most appropriate for the volunteer in this assignment? i.e. casual (jeans and t-shirts), professional, formal etc.)

_____________________________________________________________________________

What hours will the volunteer work? _______________________________________________

How many days each week? _____________________ Days off? ______________________

HOUSING AND MEALS

What type of lodging can you provide? ____________________________________________

Host family: _________________________________________________________________

Agency housing _______________________________________________________________

Other _______________________________________________________________________

If you are providing hosts for the volunteers, please have the hosts complete the Host Application Form attached. Otherwise, in the following lines, please describe the housing, including:

number of people per lodging

type of furnishings

bathroom - private, shared, or down the hall

housing mailing address and any other relevant housing information

______________________________________________________________________________

What type of meals do you provide? (i.e. - restaurant vouchers, meals with host family, meals at agency cafeteria, money for groceries (cooking facilities in lodging), or other)

_____________________________________________________________________________

Please describe the means of transportation from the housing to the agency:

_____________________________________________________________________________

- AGENCY CONTRACT-

I hereby submit the Agency Application as a request for (name of agency) ______________________________________________________________________________ to participate in the International Volunteer Program (IVP). Should this application be approved, the aforementioned agency agrees to provide or arrange for housing and board (3 meals per day) to the IVP volunteers assigned to the agency during the duration of the volunteer assignment. The agency also agrees to assist with such work related expenses as uniforms (if required) and transportation costs to and from the work site. I understand that the IVP volunteers will be given meaningful positions within this agency, as detailed above, and will be working up to, but no more than, 40 hours per week, 5 days per week. I agree to supervise the volunteers assigned to my agency.

I hereby release and forever discharge the International Volunteer Program, all participating volunteers, La Société Française de Bienfaisance Mutuelle, The French Hospital Foundation, their trustees, directors, employees, officers and staff, including their respective properties, from any and all damages arising from or related to any injury, illness, or death and/or property damage sustained by the agency, its personnel, its clients or any other person or entity, during the agency’s participation in the International Volunteer Program.

I hereby agree to defend and hold harmless all participating volunteers, The International Volunteer Program, La Société Française de Bienfaisance Mutuelle, The French Hospital Foundation, their trustees, directors, employees, officers and staff, including their properties, from any and all damages, including but not limited to costs, fees, attorneys’ fees, and/or judgments, relating to or in any way connected to the agency’s participation in the International Volunteer Program, including but not limited to all the acts and omissions of the agency and its personnel during said Program.

I hereby declare that I read carefully this contract and understand its content.

Signature: __________________________________________ Date: _________________

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