SECTION 1: CONTACT INFORMATION

SECTION 2: EDUCATION

Highest Level of Education: - High School Some College Associate's Degree Bachelor's Degree Master's Degree Doctorate J.D. M.D.

Please List the schools you attended from the rmost recent:

Please list any other degrees or certifications held and year received

Please list any other academic experience that you think would be relevant to your application:

SECTION 3: WORK HISTORY
Provide the following information regarding your three most recent jobs.

Please list any specific work experience you think might be releveant to your application:

SECTION 4: REFERENCES
List 3 people you would like to use as references. At least TWO of the references should be professional (former supervisors, for example).

SECTION 5: MORE INFORMATION

Why are you applying to Long Way Home?

Describe your past volunteering experience;

Decribe any international experence you have (work/ study abroad / travel)

SECTION 6: SKILLS ASSESSMENT
Please mark the boxes of any skill areas in which you are interested in working AND have experience.

I do not have any of the following skills but am willing to learn:

SECTION 7: LANGUAGE ASSESSMENT

Rate your Spanish speaking abilities (1=beginner): 1 2 3 4 5

Rate your Spanish writing abilities (1=beginner): 1 2 3 4 5

Rate your Spanish reading abilities (1=beginner): 1 2 3 4 5

Tell us about any Spanish education you've had including any practical experience with the language

SECTION 8: PHYSICAL FITNESS ASSESSMENT
Please rank your level of physical fitness: - Excellent Good Average Poor
Can you work with hand tools such as shovels, hoes, hammers, machetes, etc.? - yes no
Are you comfortable walking up and down lots of hills? - yes no
Would you have difficulty lifting 30-50 pounds? - yes no

Please list any medical conditions you have that would interfere with performing physical labor. (Long Way Home will require a full medical history prior to service.)

Note: To protect your safety and that of others volunteering, Long Way Home may require that you undergo a physical prior to service. It should be noted that anytime you visit a foreign country, you should consider getting a physical. Feel free to contact us if you would prefer to discuss this in person.

SECTION 9: CRIMINAL OR NON-CRIMINAL HISTORY
Please list any misdemeanor or felony convictions (excluding minor traffic violations), and please explain.

By submitting this form, I HEREBY CERTIFY that the above repsonses are true and complete and that I have not knowingly withheld any facts, circumstances or other information which would, if disclosed, affect my volunteer service. I further understand that any false or misleading statement or omission of pertinent information will result in the rejection of my application, or in dismissal if discovered subsequent to my acceptance.

I UNDERSTAND that should I be given a position with Long Way Home, the position shall be for an indefinite period of time and may be terminated, at will, at anytime, for any reason, by me or by Long Way Home without notice or without liability whatsoever.

LONG WAY HOME is an equal opportunity employer that does not discriminate on the basis of race, color, sex, religion, national origin, sexual orientation, physical handicap or disability, age, marital status, family responsibilities, political affiliation, or any other areas of discrimination prohibited by applicable law.