BARSANA EYE CAMP – 2010
APPLICATION FORM FOR VOLUNTEER SERVICES
For official use only : {OPD/WARD/OT/SUPPORT} {STAFF/VOLUNTEER}
{Write in BLOCK LETTERS. }
Name – Official: _________________________________________________________
(First Name) (Mid. Name) (Surname)
Initiated Name: __________________________________________________________
Age: _________ Sex: ________
Local Address: _____________________________________________
__________________________________________________________
__________________________________________________________
Contact No.: _______________________________________________
Email Address: _____________________________________(Write clearly & Exactly)
(We will not share this information with anyone else & it will be used only for BEC)
Qualification: ____________________________________________________________
Years in Krishna Consciousness: ____________ No. of Rounds Chanting: ___________
Counselor’s name & Phone No.: _____________________________________________
Eye Camps attended previously & services rendered _____________________________
________________________________________________________________________
Have you received Hepatitis B Vaccinations? {YES / NO}
For the Hospital Employees Only------------------ ( FOR OFFICIAL USE)
APPROVED BY APPROVED BY
Head of Department Department of HR
(ON DUTY / PERSONAL LEAVE) (ON DUTY / PERSONAL LEAVE) Approved by
(Please Specify) (Please Specify) Chief Camp Coordinator
Please choose appropriate dates for which you are applying. Please note that none of
these dates include traveling days. While arranging your schedule, please allow time for
travel so that you can make arrangements for all your duties at home to be carried on
nicely in your absence. You may check any number of boxes that you can fully commit
to the allotted time frame.
1} OPD – 31st Jan. to 4th Feb. 2010. 2} Yatra 1 - 5th Feb. & 6th Feb. 2010.
3} IPD 1 – 1st Feb. to 8th Feb.2010. 4} Yatra 2 - 9th Feb. & 10th Feb. 2010.
5} IPD 2 – 9th Feb. to 18th Feb. 2010. 6} Yatra 3 - 19th Feb. & 20th Feb. 2010.
7} FOLLOW-UP – II { 1st WEEK OF THE MARCH / APRIL.}
RECENT
PHOTO
AFFIX
HERE
OPD YATRA-1 IPD-1 YATRA-2 IPD-2 YATRA-3 FOLLOW-UP-2
{OT/WARD} {OT/WARD}
FOR OFFICE USE ONLY
OPD IPD – 1 IPD – 2 SUPPORT APPROVED
CONFIRMED
{WARD / OT) {WARD / OT}
COPY FOR BARSANA EYE CAMP – 2010 COMMITTEE
Received with thanks from ________________________________________________
DD/ CHEQUE OF 500/- as deposit in favor of Shri Chaitanya Seva Trust – Barsana
Eye Camp A/C.
Date:
Received: _______________________________________________________________
(signature & name of the person in Accounts Department)
COPY OF ACCOUNT DEPARTMENT, BHAKTIVEDANTA HOSPITAL
Received with thanks form ________________________________________________
DD/ CHEQUE OF 500/- as deposit in favor of Shri Chaitanya Seva Trust – Barsana
Eye Camp A/C.
Date:
Received: _______________________________________________________________
(signature & name of the person in Accounts Department)
RECEIPT FOR THE VOLUNTEER / PARTICIPANT OF BEC-2010
Received with thanks form ________________________________________________
DD/ CHEQUE OF 500/- as deposit in favor of Shri Chaitanya Seva Trust – Barsana
Eye Camp A/C.
Date:
Received: _______________________________________________________________
(signature & name of the person in Accounts Department)
N.B.: FOR FURTHER DETAILS CONTACT: 9324809530
MADHUKAR SALI ( MADHUKRISHNA DAS)
===============================================================
VOLUANTARY CONSENT FORM
BARSANA EYE CAMP – 2010
THIS VOLUANTARY CONSENT IS TO BE SIGN BY EVERY
VOLUANTEER AT THE CAMP.
I, ________________________ _______________ ________________________
PRINT FIRST NAME IN BOLD MIDDLE NAME PRINT LAST NAME IN BOLD
HEREBY DECLARE that I am voluntarily offering my services for the Barsana Eye
Camp to be held at Barsana, district of Mathura, UP and Organized by the Shri Chaitanya
Seva Trust, Mumbai.
I understand that there may be some biohazard risk possible during my service in Barsana
Eye Camp.
I undertake to attend all seminars, training sessions during the Orientation Program
scheduled by the organizers to get well acquainted with my service and the protocols set
up for safe & effective execution of the same.
I also take responsibility for any untold harm occurring to myself either physically. (eg.
Pin-prick injury), emotionally, mentally or spiritually as a result of my not following the
protocols that have been established and explained during the training sessions held for
the Barsana Eye Camp.
Signature:_________________
Guardian’s Signature ( if student volunteer):__________________
Date:___/___/_______
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