First Name_________________ Last Name_____________________
Contact Address______________________________ City______________________
State-Province________ Postal Code_________ Country___________
Telephone__________________ Email Address_______________________________
Passport #__________________ Exp. Date_____________ Nationality______________
Gender______ Date of Birth_____________
If Student, List School_________________________
Make sure to check with your Consulate in case your country requires a visa for entrance into Costa Rica.
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
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:
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.
this form via fax (506 country code) 447-2330 or email:
We look forward to working with you!