Good Samaritan Hospital Volunteer Application

Please answer the following questions as completely as possible to aid us in determining the best time and place for your volunteer services. The responses can be emailed to Moises Sifren, hospital administrator, at samaritano@verizon.net.do . We will respond as soon as possible. Thank you for your cooperation.

1. Name

2. Age

3. Address

4. Emergency contact in the United States (name/phone/email)

5. When would you be willing to come to La Romana and volunteer?

6. How long would you intend to stay as a volunteer?

7. How did you hear about the mission in La Romana and have you worked with us before? When?

8. What skills would you have to offer as a volunteer? (ex. Secretarial skills, computer skills, medical/nursing, cleaning/repair, construction, pharmacy, etc.)

9. What languages, other than English, are you able to speak/read/write and at what level?

10. Where is your main interest in serving? (ex. Church, hospital, batey, etc.)

11. What is your purpose in volunteering in the La Romana mission?

12. Would you be willing to learn a new skill if we do not have an area where your current skills are needed?

13. Please list two references (other than family) and how we would be able to contact them

14. How will you pay for your trip and your stay here in La Romana?

15. Is there a church who is sponsoring your trip? Which church?

16. What living arrangements will you have while in La Romana, if not staying at housing designated by the mission?

Finally, we would like each volunteer to understand that when they come to La Romana to work with the mission, they are under the auspices of both the Good Samaritan Hospital and the Maranatha Church. Behavior, conduct and work ethic need to reflect this understanding. It must also be understood that should a volunteers conduct be seen as contrary to the mission or its work, the volunteer will be asked to leave immediately, at their own expense. If you agree with this statement, please signify by stating in writing, "Yes, I agree and understand." If you do not agree to this, please contact Moises at the above email address to discuss this.

oYes, I agree and understand.
oNo, I do not agree or understand and will contact Moises Sifren.

Thank you! We hope to see you soon.

Moises Sifren ( samaritano@verizon.net.do )
Kristy Engel ( kristynurse23@hotmail.com )