Volunteer Application Rev: Sep 2014

Dear Applicant, Thank you for taking the first step on an adventure that will change your life as well as others! Please read and follow these instructions carefully and email Beth at beth@sight.org or call Beth at 903-717-7227 if you have any questions.

Things to Know Before Applying:

All Applicants: • Applicants must be at least 18 years old at time of service. • All forms should be completed in English. Please type or print legibly using black ink. • The minimum time of service is 2 weeks, but some exceptions may be made under special circumstances. • Due to given circumstances; those with certain disabilities and/or health histories may not be able to serve

with Sight.org in Africa. • A current Personal Health History, Physical Evaluation, and Immunization Checklist are required for all

Applicants. • A recent (non-Sight.org) physical evaluation (completed within the last 12 months) may be acceptable if there

has been no change in your health history since the evaluation was completed and the form provides enough information to establish a sound medical review.

• All Applicants are required to provide/raise their own funds to cover crew fees, insurance, and transportation to and from Togo, Africa, as well as all other personal expenses. If you apply for and accept a position, you will be responsible to ensure that adequate funding is in place before joining.

• If you need materials to help with your fundraising efforts, please let us know. • Three references are required prior to acceptance. However, if you are not able to provide an Employer or

Pastor/Spiritual Leader reference, you should explain why and supply a substitute reference from someone who has functioned in a supervisor or mentoring role for you.

• Once we receive your completed application, we will review it in light of our open positions, housing availability, and your qualifications. Processing is usually done in four to six weeks.

• A phone call or meeting will likely be requested by one of our staff during the application evaluation process. Medical Professionals: • Required to be licensed and have 2 years of post-licensed experience. • Include copies of current resume or CV, diploma, license, and relevant certifications with completed application. • If you currently hold defined clinical privileges at a hospital or other health care facility, please include a copy of your

current active privileges. • Please use the Medical Professional Reference form instead of the Employer’s Reference form.

Couples & Families: • Housing for couples and families are provided to accommodate for short-term and long-term family services.

o Due to the difficulty in finding short-term housing, however, short-term family volunteers may stay in the comfortable “bunkhouse” atmosphere of our ministry headquarters.

• Due to staffing limitations, we are not able to accommodate for single parent families with children under the age of 15 or families with more than 4 children.

When complete, please make a copy and send it to us by mail or email to the information listed below: Mail: Sight.org PO Box 8286 Tyler, Texas 75711 USA Email: beth@sight.org

Volunteer Application Rev: Sep 2014

Application Office use only

Vista#

Legal Name: ________________________ _______________________ __________________ ___________________ (last/surname) (first) (middle) (preferred)

Permanent Address: Street: ____________________________________________________________________________ City: ___________________________ State:__________________ Zip/Postal Code: ______________ Country: _______________________ Is this also the country where you pay taxes? q Yes qNo Email: _____________________________________________________________________________

Phone Numbers: Home: _______________________________ Work: _________________________________ (include Country Code) Cell/Mobile Number: ______________________________________

Date of birth (month/day/year): Gender q Male q Female Marital Status: q Married q Separated q Divorced q Widowed q Single If Separated, Divorced, or Widowed, when: __________________ (month/year) If married, is your spouse applying? q Yes q No Spouse’s name: _________________________________ Please list below dependent children who would serve with you: NOTE: Shipboard housing for families is very limited and generally not available for short-term crew. For children who will be attending Mercy Ships Academy on board a ship, additional information will be requested at a later time.

I am applying for: q A Volunteer Position with Sight.org in Togo, Africa. q Foundations of Sight.org (Tyler, Texas)

I am applying to serve: Indicate length of time in weeks, months, or years

_ _______________________________ (Weeks/Months/Years)

Dates available: From: (month/day/year) ____________ To: (month/day/year) _____________ To:(month/day/year) ____________________________________ Position(s) applying for (required):

Go to Sight.org/volunteer for a list of available positions on our Current Opportunities webpage.

Families: How many children will accompany you? Please answer the following questions: If you reply “yes” to questions 4-7, please explain on a separate piece of paper. qYes qNo 1. Are you aware that Sight.org is a volunteer, faith-based, non-salaried organization? qYes qNo 2. Do you have any relatives/friends who have served with Sight.org? qYes qNo 3. Are you able to provide/raise the financial support necessary to serve with Sight.org? qYes qNo 4. Have you ever been convicted of a criminal offense? qYes qNo 5. Have you ever been a subject of any claim or complaint, any investigation, or any disciplinary or remedial

action of any kind by any entity, organization, association, church, court, or governmental authority involving allegations of dishonesty, deceit, fraud, abuse, or mistreatment (physical, sexual, or emotional) of any kind of any other person, or any other act of immoral behavior?

qYes qNo 6. Have you ever engaged in any misconduct, or been a subject of any allegations of misconduct, involving the abuse, mistreatment (physical, sexual, or emotional), or neglect of a child?

qYes qNo 7. Are there any circumstances (medical or other) which could interfere with your meeting the requirements of the position for which you are applying?

Medical professionals, please answer the following: If you reply “yes”, please explain on a separate piece of paper. qYes qNo 1. Have you ever been named in a medical malpractice claim? qYes qNo 2. Have you ever been denied medica l staff appointment or had your c l in ica l privileges suspended,

limited, revoked or renewal denied?

Volunteer Application Rev: Sep 2014

qYes qNo 3. Have you ever voluntarily or involuntarily withdrawn, reduced, terminated, lost or been denied your clinical privileges?

qYes qNo 4. Have there been any successful or currently pending challenges, investigations, revocation, restriction, disciplinary action taken, suspension, reprimand, probation, denial or with-drawl to any licensure, certification, or registration to practice in any jurisdiction, or the voluntary/involuntary relinquishment of such licensure, certification, or registration?.

Education/Job History: If applying for a medical position, please attach a current résumé or C.V. For all other positions, please complete the following or attach a current résumé or C.V.

Education: Please list schools (secondary/high school/technical/college/university/seminary) you have attended. Name of school Location Dates attended Diploma/Degree

Professional Licenses or Certificates: Please list current professional, medical, technical, or marine licenses/certificates you hold. Please include copies with your application. Type/class Nationality/State

Work Experience: Please list your last 3 employers. Employer Position Dates served

1.

Address:

2.

Address:

3.

Address:

Skills Checklist: Please check the skills listed below which you feel you are most qualified to use in Sight.org. q Administration (Receptionist, Executive Assistant, HR Generalist, Data entry, etc.) q Accounting (Accountant, Bookkeeper, clerk, etc.) q IT (Computer Programmer, AV Tech, Systems Analyst, etc.) q Other Business Professional _________________________________________________ q Medical Professional q Communications (Print, Media, Videographer, Public Relations, Graphic Design, etc.) q Other (please list below)

Please list any other talent, skill, certification, or professional qualification you’d like us to know about:

Language Skills:

Language Conversational

Ability to handle basic communications

Proficient Ability to converse and comprehend

in-depth conversations Fluent

Equivalent to a native speaker

English: French:

Volunteer Application Rev: Sep 2014

Other:

Personal Profile: How did you hear about Sight.org? q Website qFriend qMagazine q News TV q News Paper qConference qChurch qOther If so, which one? ________________________________________________

Please describe any experience you have living/working outside of your own culture:

What is the name of the church you currently attend and what is your involvement there? ____________________________________________________________________________________________________________________________________________________________ Please explain why you wish to serve with Sight.org: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

M ESTIMONYTY Write a paragraph using answers to the questions below. Please write in story form and not just as answers to the questions. The typing field will enlarge as you type more information. If you are handwriting this, please use extra sheets to complete the questions.

• ?) What was my life like before I met Jesus Christ? (What were my needs? What got me interested in God • Christ as my Savior? (Who was I with? When did this happen? What did I say toHow did I come to know Jesus God?) • erent? How is my faith e diffesus meet? How is my lifWhat is my life like with Christ now? (What needs does J growing?) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Acknowledgements/Authorization I hereby consent and authorize an investigation of my past and/present employment and for Sight.org to conduct a background check relative to any matters contained in my application and any matters relevant to consideration of my service by Sight.org. I hereby waive any and all notice of disclosures required by my past and present employer(s).

In consideration of possible service by Sight.org, I hereby release and forever discharge Sight.org, my past /present employer(s) and their respective parents, subsidiaries, and successors from any and all actions, which may result from any information that is lawfully provided concerning my past employment and /or present employment. I certify that all statements given on this application are correct with no omissions. I acknowledge that if I am unable to serve with Sight.org, any funds processed on my behalf will remain the property of Sight.org and will be directed to the Sight.org General Fund if I do not reapply to serve within 18 months. I further understand that any funds processed on my behalf in excess of the direct cost of my service may remain with Sight.org.

Applicant Signature Date (month/day/year)

Volunteer Application Rev: Sep 2014

q Yes q No Do you smoke or chew tobacco? If yes, how often? _________________________ q Yes q No Do you drink alcohol? If yes, how often? _________________________

Sight.org Associates is an Equal Opportunity Employer, and conducts hiring without regard to race, color, ancestry, citizenship, age, sex, marital status, or disability of an otherwise qualified individual. In addition to being a 501(c)(3) tax-exempt corporation, Sight.org is also a faith-based religious organization. As a faith-based religious organization pursuant to the Civil Rights Act of 1964, 78 Stat.255, Section 702 (42 U.S.C. @2000e), Sight.org has the right to deny acceptance to those who do not agree and fully attest to our Statement of Faith and Sight.org Code of Conduct.

PERSONAL HEALTH HISTORY FORM Privacy notice: The primary purpose for this information is to determine medical eligibility for service. Life in a developing nation can expose you to physical stresses and health risks unlike any previously experienced. Health and physical requirements vary greatly, depending on location. Complete Personal Health History and Physical Evaluations are mandatory for service with Sight.org and must be updated and medically reviewed at least every 2 years. TO BE COMPLETED BY APPLICANT: (please use black ink and print clearly in English)

Name: (last/surname) (First) (Middle) (Preferred)

E-Mail Address:

Phone Home: Work: Cell: (please include country code)

Date of birth: _____________________________ Age: __________ Gender: Male Female (month/day/year) Position Applied for: Expected Duration of Service:

Have you ever experienced or have you ever been treated for any of the following? Please check “Yes” or “No” to each question and explain any marked “Yes” below or on a separate page. q Yes q No Frequent or severe headaches? q Yes q No Dizzy spells, fainting, or blackouts? q Yes q No Epilepsy or seizures? q Yes q No Chronic eye trouble or vision problems?

Date of last eye exam _________ q Yes q No Colonoscopy or sigmoidoscopy? q Yes q No Kidney trouble,( i.e. stones, blood, or

protein in urine?) q Yes q No Diabetes? q Yes q No Thyroid disease? q Yes q No Asthma? q Yes q No Breathing trouble, i.e. frequent,

recurrent cough or shortness of breath? q Yes q No TB, or exposure to TB? q Yes q No Pain or pressure in your chest? q Yes q No Anemia or another blood disorder? q Yes q No Heart problems, murmur, or infection? q Yes q No Stomach, liver, or intestinal problems? q Yes q No Jaundice or hepatitis?

q Yes q No Rupture or hernia? q Yes q No Rectal bleeding or black stools? q Yes q No High Blood Pressure? q Yes q No Frequent indigestion? q Yes q No Stroke? q Yes q No Cancer? q Yes q No Difficulty with hearing?

Printed name

Personal I.D. or Social Security Number

If you answered ‘yes’ to any of the questions above, please explain. If you need more space, please attach a page. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Volunteer Application Rev: Sep 2014

q Yes q No Change in bowel or bladder habits? q Yes q No Urinary problems or urinary tract

infection? q Yes q No Back pain or injury? q Yes q No Bone, tendon, or joint problems? q Yes q No Abnormal chest x-ray? q Yes q No Malaria, dysentery or other tropical disease? q Yes q No Frequent crying spells? q Yes q No Felt unusually depressed or sad? q Yes q No Persistent fatigue? q Yes q No Any other medical problems not already

mentioned? q Yes q No Tested positive to HIV? q Yes q No Tested positive to Hep B? q Yes q No Tested positive to Hep C

Volunteer Application Rev: Sep 2014

PERSONAL HEALTH HISTORY FORM, continued qYes q No Would you have a problem walking up six flights of stairs at a steady pace without stopping? qYes q No Would you have a problem walking a distance of 3 km (approximately 1.5 miles) on a level plane

at a steady pace without stopping? qYes q No Have you ever been referred to or sought consultation or treatment from a mental health

professional (counselor, psychologist, psychiatrist, pastoral, or family marriage counselor)? q Yes q No Have you ever received mental health treatment as an inpatient or as an outpatient in a day

treatment center? If you answered ‘yes’ to any of the questions above, please explain. If you need more space, please attach a page. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ LIST ALL HOSPITALIZATIONS AND MEDICAL EVACUATIONS FOR BOTH MEDICAL AND PSYCHIATRIC ILLNESSES.

Date Illness or Operation Name of hospital Location

LIST ANY CURRENT OR PAST CONGENITAL OR CHRONIC CONDITIONS.

MEDICATIONS: LIST ALL CURRENT.

Name Amount Frequency How long have you been on this medication? What are you taking it for?

ALLERGIES: List all known allergies to Food, medications, etc. and list typical reaction and treatment.

Please complete and sign below: I, ___________________________________, have completed this form to the best of my knowledge. I also understand I need to report any changes in my health status or medical treatment received prior to my joining Sight.org, including any new medical diagnoses, surgeries, or hospitalizations. Failure to do so may result in my being sent home at my expense. AUTHORIZATION & CONSENT FOR TREATMENT: Please Read Carefully I request that this Personal Health History & Physical Evaluation be forwarded to the Foundations of Sight.org in Texas and I hereby consent to the transfer to the United States of all data contained in this application and any attachments thereto, including all private personal data. I also request that this Personal Health History & Physical Evaluation be forwarded to the Foundations of Sight.org location where I will be serving in order that I may be given medical attention should that become necessary or appropriate. I certify that all statements given on this application are correct with no omissions and may result in my being sent home if health information is intentionally not disclosed. Additionally, in the course of my service with Sight.org, if I require medical treatment while outside my country, I hereby agree to the performance of such treatment, anesthetics, and operations if, in the opinion of the present physician, it is deemed necessary. ________________________________________________ ___________________________________ Applicant signature Date (month/day/year)

Volunteer Application Rev: Sep 2014

Immunizations

Listed below are the mandatory immunizations required prior to arrival!

Once approved for service, you will be sent a proof of immunization checklist to complete. The Immunization Checklist must be returned, no later than 4 weeks prior to your arrival.

The following are mandatory for ALL adult crew:

• Yellow Fever: within last 10 years (travel with documentation of yellow fever – WHO card) • Hepatitis B: series of 3 • MMR- Measles, Mumps, Rubella: series of 2 • TB skin test (PPD): within 12 months of arrival

o Result in millimeters (mm) o Negative or Positive? (if positive, chest x-ray required) o Date of Chest X-ray (within 12 months of arrival) o Chest X-ray report (please attach a copy)

• Skin testing is not required if there is a history of a prior positive skin test (which is defined as >10mm in duration, not simply redness). However we do require a chest x-ray.

PLEASE NOTE: TB testing is required even if you have received a previous BCG vaccine. A TB screening blood test can be done (Interferon-Gamma Release Assay (IGRA) such as the QuantiFERON-TB Gold or T-spot TB test) in the place of a PPD skin test. The test should be performed within 12 months of boarding the ship. The following are mandatory for those working in Hospital, Dental and Engineering departments:

• Typhoid: EITHER oral within last 5 years OR injection within last 2 years • Hepatitis A: series of 2 • Tetanus/Diphtheria: within last 10 years

The following are highly recommended for all adult crew:

• Typhoid: EITHER oral within last 5 years OR injection within last 2 years • Hepatitis A: series of 2 • Tetanus/Diphtheria: booster, within last 10 years • Pertussis: aka Whooping Cough • Polio booster: within last 10 years • HIB (Haemophilus Influenza type B): booster • Meningitis ACWY: within last 5 years • Rabies: series of 3

Children: Parents are required to ensure that their children are up to date with their childhood vaccinations. They should also seek advice from a Travel Clinic about additional vaccinations that the children may require before joining Sight.org. Please bring all vaccination documentation and a copy of the childhood vaccination schedule to Sight.org. Yellow Fever vaccination is a mandatory requirement for all children over 9 months of age.

Volunteer Application Rev: Sep 2014

PHYSICAL EVALUATION SUMMARY SHEET IMPORTANCE OF EXAMINATION: It is important for the examiner to identify all medical conditions which will require follow-up medical care or could be adversely affected by environmental conditions, such as air pollution and poor sanitation. The consequences of not identifying pre-existing health problems could be extremely serious for the examinee. As you perform the examination, keep in mind that the examinee may be assigned to a developing country where medical care is not available. All reports must be in English.

Exam Date: _____________________ Name: _______________________________________ Date of birth (mm/dd/year):________________ Age:_______ Height: _______ in/cm Weight: _______ lb/kg

Blood Pressure:_______________________ Pulse:_____________

Areas to be examined (as appropriate) Normal Abnormal Notes Skin (record lesions, body marks, scars, etc) Head, Neck, Thyroid Ear, Nose, and Throat (comment on hearing) Lymph Nodes Eyes (include funduscopic exam, visual acuity, and color

perception)

Lungs Breasts Heart (record murmurs and abnormalities) Abdomen (comment on liver and spleen) Genitalia Anus, Rectum, and Prostate (if of age) Vascular System (record peripheral pulses and varicosities) Extremities and spine Neurological (reflexes and muscle strength recorded) Psychiatric Gynecological (note last normal exam if not examined on this occasion)

Additional comments: ___________________________________________________________________________________________

___________________________________________________________________________________________

Recommendation for treatment/further follow up: ___________________________________________________________________________________________

_________________________________________________________________________________________

PHYSICIAN’S SIGNATURE DATE: (month/day/year)

Telephone: PHYSICIAN’S PRINTED NAME Email address:

Rev: June 2017

FRIEND REFERENCE FORM

Please fill in your name and address and give to a friend to complete.

Name of applicant:

Applicant’s mailing address:

(last/surname) (first) (middle initial) Sight.org, an international charity, has performed eye surgical care to the poor of Togo, Africa, since 2012. Following the example of Jesus, Sight.org brings hope and compassionate service to the poor. Applicants who serve with us are often subjected to physical and emotional stresses, which should be considered in your evaluation of their personal capabilities within Sight.org. Please visit our website at Sight.org for more information. INSTRUCTIONS: Please be honest in your appraisal of this applicant.

1. How long and in what association have you known the applicant?

2. Please evaluate the applicant in the following areas: o Character:

o Skills, abilities, strengths, and talents:

o Emotional stability:

3. Do you have any reservations regarding this person’s service with Sight.org?

Your Name (Please print):

Your Address:

Title:

Organization: Tel: Email:

To the best of my knowledge, all information shared in this reference is correct and accurate.

Signature Date

Rev: June 2017

Medical Professional REFERENCE FORM

Medical Professionals: Please fill in your name and address and give to a current professional reference who can comment on your clinical practice. If not self-employed, this should be your employer.

Name of applicant: Applicant’s mailing address:

(last/surname) (first) (middle initial) Sight.org, an international charity, has performed eye surgical care to the poor of Togo, Africa, since 2012. Following the example of Jesus, Sight.org brings hope and compassionate service to the poor. Applicants who serve with us are often subjected to physical and emotional stresses, which should be considered in your evaluation of their personal capabilities within Sight.org.

Please visit our website at Sight.org for more information.

INSTRUCTIONS: Please be honest in your appraisal of this applicant .

1. How long and in what association have you known the applicant?

2. Please evaluate the applicant in the following areas: o Character:

o Clinical skills, abilities, strengths, and talents:

o Relations with patients and staff:

o Emotional stability:

o Ability to work independently in a austere medical resource environment

3. Do you have any reservations regarding this person’s service with Sight.org?

Your Name (Please print): Your Address:

Title:

Organization: Tel: Email:

To the best of my knowledge, all information shared in this reference is correct and accurate.

Signature Date

Rev: June 2017

EMPLOYER REFERENCE FORM

Please fill in your name and address and give to your current employer to complete. If you are not currently employed, please ask a former employer or mentor to complete this form and send it along with an explanation.

Name of applicant:

Applicant’s mailing address:

(last/surname) (first) (middle initial)

Sight.org, an international charity, has performed eye surgical care to the poor of Togo, Africa, since 2012. Following the example of Jesus, Sight.org brings hope and compassionate service to the poor. Applicants who serve with us are often subjected to physical and emotional stresses, which should be considered in your evaluation of their personal capabilities within Sight.org. Please visit our website at Sight.org for more information. INSTRUCTIONS: Please be honest in your appraisal of this applicant.

1. How long and in what association have you known the applicant?

2. Please evaluate the applicant in the following areas: o Character:

o Skills, abilities, strengths, and talents:

o Emotional stability:

3. Do you have any reservations regarding this person’s service with Sight.org?

Your Name (Please print):

Your Address:

Title:

Organization: Tel: Email:

To the best of my knowledge, all information shared in this reference is correct and accurate.

Signature Date

Rev: June 2017

PASTOR OR SPIRITUAL LEADER REFERENCE FORM

Please fill in your name and address and give to your Pastor or Spiritual Leader to complete. If you do not have a Pastor or Spiritual Leader, please ask a teacher, coach, or mentor to complete the form and send it in along with an explanation.

Name of applicant:

Applicant’s mailing address:

(last/surname) (first) (middle initial) Sight.org, an international charity, has performed eye surgical care to the poor of Togo, Africa, since 2012. Following the example of Jesus, Sight.org brings hope and compassionate service to the poor. Applicants who serve with us are often subjected to physical and emotional stresses, which should be considered in your evaluation of their personal capabilities within Sight.org. Please visit our website at Sight.org for more information. INSTRUCTIONS: Please be honest in your appraisal of this applicant.

1. How long and in what association have you known the applicant?

2. Please evaluate the applicant in the following areas: o Character:

o Skills, abilities, strengths, and talents:

o Emotional stability:

3. Do you have any reservations regarding this person’s service with Sight.org?

Your Name (Please print):

Your Address:

Title:

Organization: Tel: Email:

To the best of my knowledge, all information shared in this reference is correct and accurate.

Signature Date

Rev: June 2017

Sight.orgVOLUNTEERAGREEMENTANDNOTICEANDPERMISSIONTOBETREATED

You are participating in a mission project sponsored in whole or in part by Sight.org. Please initial each line to show your agreement with the following statements. _____ Mission projects can expose the participant to increased risks to person and property. By this agreement

you are assuming the risk of harm to yourself and/or your property.

_____ In the event you and your property are harmed while participating in this project, you agree to release,

discharge, and forever hold Sight.org, its directors, officers, employees, administrators, team leaders,

coordinators, members and agents harmless and indemnify them, from any and all claims, demands or

suits, known or unknown, fixed or contingent, liquidated or unliquidated, arising from your participation in this project.

_____ In addition, you agree that you will not institute any action or suit, in law or in equity, against Sight.org, its

directors, officers, employees, administrators, team leaders, coordinators, members or agents for any

harm to you or your property while participating in this project.

_____ In the event that you or your property are harmed while participating in this project, you agree to notify, in

writing, the Sight.org staff of the damage and schedule an appointment, in order to discuss the matter.

_____ If discussions fail, you agree that any and all disputes or claims you feel you may have against Sight.org, its

directors, officers, employees, administrators, team leaders, coordinators, members, or agents, shall be submitted to mediation prior to any further legal action. The Mediator will be mutually chosen by you and

Sight.org and any fees for said mediation will be equally born by the parties.

_____This agreement is made and performable in the State of Texas and shall be construed in accordance with

the laws of the State of Texas.

_____In the event that any portion of this agreement is determined to be unenforceable, the remaining provisions

remain in full force and effect.

_____The above provisions are binding on me, my heirs, assigns or legal representatives. *I understand that my deposit is non-refundable and that I will be responsible for airline tickets purchased in my name upon cancellation. *The training meetings for this mission project are critical for the spiritual unity and physical preparation of the entire team. I commit to faithfully attend all meetings at the scheduled times. *I will refrain from using alcohol or tobacco while on the mission project. *By signing this document I acknowledge that my photograph and/or statements may be used in any fashion, by Sight.org, in its sole discretion, including but not limited to, publications, videos and websites.

DO NOT use my photograph for future promotional materials.

Signature _________________________Print Name ___________________________DATE: _______________

FORMINORSONLY:NOTE:IFVOLUNTEERNAMEDABOVEISUNDERTHEAGEOF18,THEFOLLOWINGFORMMUSTBESIGNEDBYTHEMINOR(ListedAbove)ANDBOTHPARENTSORGUARDIANSOR,IFMARRIEDMINOR,BYTHEIRSPOUSEONTHELINESBELOW. Signature of Minor’s Parent or Guardian _____________________________________________________

Signature of Minor’s Parent or Guardian _________________________________________________________

If Married, Signature of Minor’s Spouse __________________________________________________________

Rev: June 2017

Criminal Background Policies Policy for Criminal Background Screening: All new or potential volunteers must complete an application packet which includes a Background Verification Release Form. In order to conclude the background check volunteers must include their driver’s license number. Once the criminal background has been finished, Sight.org staff will evaluate the information and a decision will be made. Background Check Offenses: As a general rule, subject to the specific nature and severity of the offense(s), the volunteer applicant may be deemed ineligible to work or provide services to Sight.org if the volunteer is identified as having committed any of the following offenses. Sight.org reserves the right to extend considerations identified based on the seriousness and time since the offense(s):

• An offense against a minor within the past ten years. • A sexual offense within the past ten years. • Any matter involving a felony within the past ten years. • A drug offense within the past five years. • An alcohol offense within the past three years. • Any other offense that is deemed relevant to the subject’s assignment within the past five years. • Any re-occurring matter involving any other type of criminal offense, especially if more than one

occurrence of the same type of offense is alleged to have taken place within the previous eight years.

Although a disqualification is possible, a previous conviction does not automatically disqualify an applicant from consideration of volunteering with Sight.org. The Executive Director and the position supervisor will together consider the following factors in determining whether a candidate is eligible for volunteering with Sight.org.

• The relevance of the conviction to the duties and responsibilities of the position for which selected. • The nature of the conviction(s) • The age of the candidate when the illegal activity occurred • The dates of the convictions • The candidate’s record since the date(s) of the conviction(s)

Disqualification from Volunteer Participation: The following rules shall apply if Sight.org learns (via criminal background search) that a prospective volunteer/host has been convicted of, has pled guilty to, has deferred adjudicative for, or has pled no contest to one of the following crimes under the laws of any State within the United States, or any other nation. Automatic Disqualification:

• Homicide • Crimes of rape, criminal sexual penetration, criminal sexual contact, incest, indecent exposure, or other

related sexual offenses • Crimes using weapons • Arson • Any violent crime, felony drug-related offense or trafficking in controlled substances • Crimes involving child abuse, neglect, or residing on the same premises as a registered sex offender • Crimes involving adult abuse, neglect or financial exploitation

All information supplied by potential volunteer is held in the strictest confidence and not divulged to any other staff member, board member or volunteer.

Rev: June 2017

Background Verification Release Form

AGENCY INFORMATION: PLEASE PRINT LEGIBLY Date

Agency Name Sight.org PO Box 8286 Tyler, TX 75711

Contact Name Beth Reed – Volunteer Coordinator Phone Number 903-830-2065

APPLICANT INFORMATION:

Applicant Full Name (First, Middle, and Last)

Maiden or Other Name(s) Used

Current Address City State Zip Code

County

Date of Birth

Driver’s License Number Exp. Date State Issued

Position Applied For Sight.org Volunteer

Gender q Male q Female Race q Black q White q Hispanic q Asian q American Indian q Other ___________

I hereby authorize SIGHT.ORG and or its Service Provider to request and receive any and all background information about or concerning me, including but not limited to my Criminal History, Driving Record, and if needed other entities including my Present and Past Employers. The criminal history, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications and delinquent conduct as committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for a volunteer position with Sight.org. I also understand that as long as I remain a volunteer here, the criminal history check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by Sight.org and a procedure is available for clarification, if I dispute the record as received. I also understand that the criminal history could contain information presumed to be expunged. I further release and discharge SIGHT.ORG and their Service Provider and all of their Subsidiaries, Affiliates, Officers, Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request for information or records pursuant to this authorization and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable. I acknowledge that I have voluntarily provided the above information for volunteer purposes, and I have carefully read and understand this authorization.

Applicant’s Signature

Date

Rev: June 2017

Applicant’s Printed Name

Parent/Guardian’s Signature (if under 18 years of age)

VOLUNTEER PERSONAL INFORMATION PERMISSION FORM

This is your contact information that will be used for Staff or your fellow volunteers only to contact you to substitute a shift _____I give permission to Sight.org Volunteer Services or Sight.org staff members to give my contact information to other Sight.org volunteers. _____I DO NOT give permission to Sight.org Volunteer Services or Sight.org staff members to give my contact information to other Sight.org volunteers.

Sight.org VOLUNTEER AGREEMENT

I agree to serve as a Sight.org volunteer and commit to the following:

1. To complete all required training for the volunteer position I accept.

2. To abide by all guidelines and procedures of Sight.org.

3. To respect the confidential nature of all records and personal contact with clients.

4. To work cooperatively with staff and other volunteers.

5. To meet time and duty commitments, or give adequate notice so that alternate arrangements can be made.

Sight.org CONFIDENTIALITY FORM ALL VOLUNTEERS

I understand that I am required to complete all training for the volunteer position I accept, to abide by all guidelines and procedures of Sight.org, to respect the confidential nature of all records and personal contact with clients, and to work cooperatively with staff and other volunteers.

Rev: June 2017

Sight.org POLICY AND PROCEDURES

I have read the above and have received, read and understand the Sight.org Policy and Procedures. Signature______________________________ Date__________________

Legal Name: first: middle: preferred: Street: undefined: undefined_2: City: State: ZipPostal Code: Country: Email: Is this also the countrywhere you pay taxes Yes: No: Home: Work: CellMobile Number: Date ofbirthmonthdayyear: IfSeparated Divorced or Widowed when: Spouses name: WeeksMonthsYears: Dates available: Frommonthdayyear: Tomonthdayyear: Positionsapplying for required Go to Sightorgvolunteer for a listofavailable positions on our Current Opportunities webpage: Families Howmanychildren willaccompany you: Name ofschoolRow1: LocationRow1: Dates attendedRow1: DiplomaDegreeRow1: Name ofschoolRow2: LocationRow2: Dates attendedRow2: DiplomaDegreeRow2: Name ofschoolRow3: LocationRow3: Dates attendedRow3: DiplomaDegreeRow3: TypeclassRow1: NationalityStateRow1: TypeclassRow2: NationalityStateRow2: TypeclassRow3: NationalityStateRow3: Employer: 1: Address: PositionRow1: Dates servedRow1: 2: Address_2: PositionRow2: Dates servedRow2: 3: Address_3: PositionRow3: Dates servedRow3: ITComputer Programmer AVTech Systems Analyst etc: Please list anyother talent skill certification or professionalqualification youdlike us to know about: Conversational Abilityto handle basic communicationsEnglish: Proficient Abilityto converse andcomprehend indepth conversationsEnglish: Fluent Equivalentto a native speakerEnglish: Conversational Abilityto handle basic communicationsFrench: Proficient Abilityto converse andcomprehend indepth conversationsFrench: Fluent Equivalentto a native speakerFrench: Other: Website Friend Magazine News TV News Paper Conference Church Other: Please describe anyexperience you have livingworkingoutside ofyour own culture 1: Please describe anyexperience you have livingworkingoutside ofyour own culture 2: Whatis the name ofthe church you currentlyattendandwhatis your involvementthere 1: Whatis the name ofthe church you currentlyattendandwhatis your involvementthere 2: Please explain whyyou wish to serve withSightorg 1: Please explain whyyou wish to serve withSightorg 2: Please explain whyyou wish to serve withSightorg 3: Please explain whyyou wish to serve withSightorg 4: Please explain whyyou wish to serve withSightorg 5: Please explain whyyou wish to serve withSightorg 6: Please explain whyyou wish to serve withSightorg 7: 1_2: 2_2: 3_2: 4: 5: 6: 7: 8: 9: processed on mybehalfin excess of the direct costofmyservice may remain withSightorg: Date monthdayyear: Printedname: PersonalID or SocialSecurityNumber: Name lastsurname First Middle Preferred: EMailAddress: Date ofbirth: Gender: OffPosition Appliedfor: ExpectedDuration ofService: Yes No Chronic eye trouble or vision problems: Ifyou answeredyes to any ofthe questions above please explain Ifyou needmore space please attach a page: 1_11: 2_11: 1_12: 2_12: 3_10: 1_13: 2_13: 3_11: 1_14: 2_14: 3_12: 1_15: 2_15: 3_13: 1_16: 2_16: 3_14: 1_17: 2_17: 3_15: 1_18: 2_18: 3_16: 1_19: 2_19: 3_17: 1_20: 2_20: 3_18: 1_21: 2_21: 3_19: 1_22: 2_22: 3_20: 1_23: 2_23: 1_24: 2_24: 3_21: DateRow1: Illness or OperationRow1: Name ofhospitalRow1: LocationRow1_2: DateRow2: Illness or OperationRow2: Name ofhospitalRow2: LocationRow2_2: DateRow3: Illness or OperationRow3: Name ofhospitalRow3: LocationRow3_2: NameRow1: AmountRow1: FrequencyRow1: How longhave you been on this medicationRow1: Whatare you takingitforRow1: NameRow2: AmountRow2: FrequencyRow2: How longhave you been on this medicationRow2: Whatare you takingitforRow2: NameRow3: AmountRow3: FrequencyRow3: How longhave you been on this medicationRow3: Whatare you takingitforRow3: Please complete andsign below: Date monthdayyear_2: Name: Exam Date: undefined_3: Date ofbirth mmddyear: Age: incm: lbkg: BloodPressure: Pulse: NormalSkinrecordlesions bodymarks scars etc: AbnormalSkinrecordlesions bodymarks scars etc: NotesSkinrecordlesions bodymarks scars etc: NormalHead Neck Thyroid: AbnormalHead Neck Thyroid: NotesHead Neck Thyroid: NormalEar Nose andThroatcommenton hearing: AbnormalEar Nose andThroatcommenton hearing: NotesEar Nose andThroatcommenton hearing: NormalLymphNodes: AbnormalLymphNodes: NotesLymphNodes: NormalEyes include funduscopic exam visualacuity andcolor perception: AbnormalEyes include funduscopic exam visualacuity andcolor perception: NotesEyes include funduscopic exam visualacuity andcolor perception: NormalLungs: AbnormalLungs: NotesLungs: NormalBreasts: AbnormalBreasts: NotesBreasts: NormalHeart recordmurmurs andabnormalities: AbnormalHeart recordmurmurs andabnormalities: NotesHeart recordmurmurs andabnormalities: NormalAbdomen commenton liver andspleen: AbnormalAbdomen commenton liver andspleen: NotesAbdomen commenton liver andspleen: NormalGenitalia: AbnormalGenitalia: NotesGenitalia: NormalAnus Rectum andProstate ifofage: AbnormalAnus Rectum andProstate ifofage: NotesAnus Rectum andProstate ifofage: NormalVascular Systemrecordperipheralpulses andvaricosities: AbnormalVascular Systemrecordperipheralpulses andvaricosities: NotesVascular Systemrecordperipheralpulses andvaricosities: NormalExtremities andspine: AbnormalExtremities andspine: NotesExtremities andspine: NormalNeurologicalreflexes andmuscle strengthrecorded: AbnormalNeurologicalreflexes andmuscle strengthrecorded: NotesNeurologicalreflexes andmuscle strengthrecorded: NormalPsychiatric: AbnormalPsychiatric: NotesPsychiatric: NormalGynecologicalnote last normalexam ifnotexaminedon this occasion: AbnormalGynecologicalnote last normalexam ifnotexaminedon this occasion: NotesGynecologicalnote last normalexam ifnotexaminedon this occasion: Additionalcomments: 1_25: 2_25: 1_26: 2_26: 1_27: 2_27: 1_28: 2_28: 1_29: 2_29: 1_30: 2_30: 1_31: 2_31: 1_32: 2_32: 1_33: 2_33: 1_34: 2_34: 1_35: 2_35: 1_36: 2_36: 1_37: 2_37: Recommendation for treatmentfurther follow up: 1_38: 2_38: 1_39: 2_39: 1_40: 2_40: 1_41: 2_41: undefined_4: undefined_5: undefined_6: undefined_7: undefined_8: undefined_9: undefined_10: undefined_11: undefined_12: undefined_13: DATE monthdayyear: PHYSICIANS PRINTED NAME: Telephone: Emailaddress: lastsurname: first_2: middle initial: Applicants mailingaddress: 1 How longandin whatassociation have you known the applicant: 2 Please evaluate the applicantin the followingareas o Character o Skills abilities strengths andtalents o Emotionalstability: 3 Do you have any reservations regardingthis persons service withSightorg: Your Name Please print: Title: Your Address: Organization: Tel: Email_2: Date: first_3: 1 How long and in whatassociation haveyou known theapplicant: 2 Please evaluate the applicant inthe followingareas o Character o Clinicalskills abilitiesstrengthsandtalents o Relations withpatients andstaff o Emotional stability o Ability to work independently in a austere medicalresource environment: 3 Do you have any reservations regarding this personsservice with Sightorg: Your Name Please print_2: Title_2: Your Address_2: Organization_2: Tel_2: Email_3: Date_2: first_4: Applicants mailingaddress_2: lastsurname_2: 1 How longandin whatassociation have you known the applicant_2: 2 Please evaluate the applicantin the followingareas o Character o Skills abilities strengths andtalents o Emotionalstability_2: 3 Do you have any reservations regardingthis persons service withSightorg_2: Your Name Please print_3: Title_3: Your Address_3: Organization_3: Tel_3: Email_4: Date_3: first_5: middle initial_2: Applicants mailingaddress_3: lastsurname_3: 1 How long andin whatassociation have you known the applicant: 2 Please evaluate the applicantin the followingareas o Character o Skills abilities strengths andtalents o Emotionalstability_3: 3 Do you have any reservations regardingthis persons service withSightorg_3: Your Name Please print_4: Title_4: Your Address_4: Organization_4: Tel_4: Email_5: Date_4: Mission projects can expose the participantto increasedrisks to person andproperty By this agreement: In the eventyou andyour property are harmedwhile participatingin this project you agree to release: In addition you agree thatyou willnotinstitute any action or suit in law or in equity against Sightorg its: In the eventthatyou or your propertyare harmedwhile participatingin this project you agree to notify in: Ifdiscussions fail you agree thatany andalldisputes or claims you feelyou mayhave against Sightorg its: This agreementis made andperformable in the State ofTexas andshallbe construedin accordance with: In the eventthatany portion ofthis agreementis determinedto be unenforceable the remainingprovisions: The above provisions are bindingon me myheirs assigns or legalrepresentatives: sole discretion includingbutnotlimitedto publications videos andwebsites: OffPrintName: DATE: undefined_14: undefined_15: Automatic DisqualificationRow1: Date_5: AgencyName SightorgPOBox 8286Tyler TX75711: ContactName BethReed Volunteer Coordinator: Phone Number 9038302065: ApplicantFullName First Middle andLast: Maiden or Other Names Used: CurrentAddress: City State Zip Code: County: Date ofBirth: Drivers License Number: Exp Date: State Issued: Position AppliedFor SightorgVolunteer: Date_6: undefined_16: undefined_17: Applicants PrintedName: contact information to other Sightorg volunteers: give my contact information to other Sightorg volunteers: Date_7: Check Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffCheck Box25: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box29: OffCheck Box30: OffCheck Box31: OffCheck Box32: OffCheck Box33: OffCheck Box34: OffCheck Box35: OffCheck Box36: OffCheck Box37: OffCheck Box38: OffCheck Box39: OffText40: Text41: Text42: Check Box43: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffCheck Box47: OffCheck Box48: OffCheck Box49: OffCheck Box50: OffCheck Box51: OffCheck 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