Lybomi Wildlife 7 VOLUNTEER APPLICATION AND INDEMNITY FORM Please complete this form with as much detail as possible; to ensure your acceptance to the program.General DetailsName First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Nationality Tel No:Mobile NoEmail Date of Birth DD slash MM slash YYYY Occupation Sex Passport No Country of Issue Next of KinName First Last Relationship PhoneEmail Tel No:Mobile NoPersonal InformationLanguage spoken and understood Are you vegetarian Do you have any special dietary requirements Are you a student? If yes, specify your field of study Do you have a criminal record? If yes, please specify Medical InformationDo you have any medical conditions that we should be aware of Are you on any medication? If yes, give a brief outline Do you have any allergies that we should be aware of? If yes, give brief outline Have you been hospitalized during the last year About the Volunteer/Work ProgramWhy do you want to volunteer What do you feel you have to offer Do you have any skills or expertise in the field of animal care/welfare? If yes, give a brief outline What are your interests and skills Please list any previous volunteer experience What do you hope to achieve by joining this volunteer work experience Any general information you might think relevantWhat are your proposed dates for staying at LybomiArrival Date DD slash MM slash YYYY Departure Date DD slash MM slash YYYY GENERAL CONSENT AND INDEMNITY: I, (State full name in field below)(Required) General Consent and Indemnity(Required) Please click this box to accept your understanding and acceptance of the below stated terms: I, as named above, with address, and personal details as stated above, agree to the following, whilst at the rehabilitation project run by Lybomi Wildlife (Pty)Ltd.: I agree that Lybomi Wildlife (Pty)Ltd., it’s employees, recruiting-agents & any 3rd party operators; accepts no responsibility for any death, injury or illness sustained, contracted or suffered by any person, or theft, loss or damage to property or person, occurring within and arising from a visit or stay on its premises or during any excursions, and or road shuttle services offered by Lybomi Wildlife (Pty)Ltd. howsoever caused and whether allegedly due to negligence, or arising from the use of any facility supplied or made available or from any alleged defect in any equipment, services supplied or made available, or from any liquid or foodstuff supplied or arising in any manner and from or cause whatsoever. I acknowledge that I have read and understood the below stated code of conduct and will adhere to same, I acknowledge and consent that no refund will be considered in any form for breach of any serious offenses resulting in termination of the volunteering period. The code of conduct has been adopted to ensure that volunteers have an enjoyable and safe experience at Lybomi Wildlife: Minor Offences General Bad Conduct // Breach of Safety Rules // Damage or misuse of project or volunteer property // Discrimination in any form // nonadherence to photographic policy 1st Offence - Verbal Warning 2nd Offence - Written Warning 3rd Offence - Termination Serious Offences Theft // Drinking on duty // Under the influence of drugs 1st Offence - Immediate Termination Video and Photography Policy Lybomi’s remote location in the Northern Province of South Africa offer the ultimate of-the-beaten track volunteer experience, this policy helps you understand the strict rules enforced governing our video and photography policy that are meant to maximize your experience here with us. The IUCN has strict guidelines governing the photography of wild animals within a rehabilitation context, therefore as custodians of these magnificent animals, we have an obligation to adhere to international standards and regulations pertaining to wildlife photography - all videos and photographs are carefully monitored to ensure the responsible use of those materials. No videos or pictures of the following: ⊗ Any kissing of an animal ⊗ No animal with a bottle ⊗ No animal higher than the shoulder of the caretaker ⊗ No animal on the head or shoulder of a caretaker ⊗ No animal in the face of a caretaker ⊗ No Video or Pictures in Clinic ⊗ No Video or Pictures in Quarantine ⊗ No Video or pictures bathing an animal Absolutely no videos or pictures are allowed to be shared or posted on any social media platform or in any printed platform of any kind without first obtaining permission. As a valued guest, we expect of you to honour this policy, not just for us but also as a custodian of these magnificent animals. All video material, photographs etc. taken at Lybomi Wildlife as well as any information regarding the rehabilitation process & procedures or any animal at the centre will be treated as confidential and may not be ‘published’ by any volunteer without first obtaining permission to do so. You irrevocably consent and give your express permission that any and all photographic and video content where you might be depicted in, can be published by Lybomi Wildlife (Pty) Ltd. in and on any platform and medium. Vaccinations The following vaccinations/inoculations are recommended by the South African Government Institute of Communicable Diseases, vaccinations in question are: Hepatitis A, Tetanus and Rabies when working with animals. I acknowledge that it is my own choice to either have, or otherwise not to have the recommended vaccinations / inoculations. General acceptance By submitting this application: I consent that my electronic signature hereto will be legally binding, further more; I consent to the rules of the general code of conduct, further more; I affirm that the facts set forth in this application and indemnity form are true and complete and that I have read, understood and agree to all the terms that are contained in this application. I understand that if I am accepted as a volunteer, any false statement, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal from the volunteer program. (Required)Signature(Required) Yes, I agree No, I don't agree Date(Required) DD slash MM slash YYYY Come on In! Volunteer with us Contact Phone +27 733 11 4823 Mail Mias@Lybomi.co.za
