Volunteer Application

General Information

First Name_________________ Last Name_____________________

Contact Address______________________________ City______________________

State-Province________ Postal Code_________ Country___________

Telephone__________________ Email Address_______________________________

Passport #__________________ Exp. Date_____________ Nationality______________

Gender______ Date of Birth_____________

Occupation________________ If Student, List School_________________________
Make sure to check with your Consulate in case your country requires a visa for entrance into Costa Rica.

Health Information
Do you have Health Insurance that is valid in Costa Rica:

Policy Name and #:

Health Insurance Phone #:

Name of person to contact in case of an emergency:

Telephone #________________ Email address____________________

-An option of Medical Insurance for Volunteers is:
MEDEX INTERNATIONAL (888) MEDEX-00 or 410-453-6300

Concerning your stay with Habitat For Humanity

Date of arrival______________ Departure date____________

Are you traveling: Alone/ With Companion/ With Group

What region of Costa Rica are you most interested to work in (see our Affiliate Page for affiliate-specific information):

A. San Ramón (National Office)___ B. San Ramón (Affíliate Office)___
C. Cartago___ D. Esparza___
E. Nicoya___ F. Monteverde___
G. Area With Most Need___

Do you require lodging: Home/Stay/Hotel/Other

Do you have any special dietary requirements:

How is your Spanish:
Fluent/I can communicate/Beginner/None

List any special skills that you might offer:

Why are you interested in volunteering with Habitat Costa Rica:

Habitat Costa Rica benefits greatly from the donations of volunteers through many forms.
Donation you would like or be able to make $

Monetary donations enable us to build more homes, but we also need donations of the following office supplies, to more efficiently serve our purpose, to provide adequate housing in Costa Rica. Please see our WISH LISTS for more information.

With donation of computer or printer Habitat Costa Rica will arrange free pickup from the National Airport.

Please return this form via fax (506 country code) 447-2330 or email: volunteerhabitatCR@yahoo.com
We look forward to working with you!