RIAES - Rural India Awareness and Educational Society

Application Form

Note: Required Field in Red Color
Please read the application form carefully and fill it thoroughly and thoutfully:

Your Name:
Email Address:
Date of Birth:
Telephone No:
Fax No:
Mention the name of program : (which you applying)
Mention the date of program :(which you applying)
Your Name (as it appears in your passport)
Nationality
Passport No:
Expiry date:
Place of Issue:
Address:
Address permanent (if different):
Email Address:
Telephone No:
Fax No:
Father name:
Address :
Email Address:
Telephone No:
Fax No:
Mother Name:
Address :
Email Address:
Telephone No:
Fax No:

WHOM SHOULD WE CONTACT IF NOT YOUR PARENTS
Name:
Address :
Email Address:
Telephone No:
Fax No:
How did you hear about RIAES?
Please tell us briefly about yourself, your education, your interest and your family:
Why do you want to participate in RIAES program?
Have you ever traveled abroad if yes, why and where and what were your experience:
What is you're greatest concern about participating in RIAES:

APPLICATION FEE
An application fee of USD 100 in the form of a certified cheque payable to RIAES.The fee is counted towards your program fee if selected. If for any reason the prospective volunteer is not selected the fee is non- refundable.
MEDICAL AND HEALTH FORM
Please answer the following questions by select yes and no. All the information provided by you in this form will be kept strictly confidential.
Your weight:
Your height:
Your medical insurance policy No:
Do you take medications for any health problem?
Do you have any allergies?
Do you use any drugs?
Do you smoke or chew tobacco?
Do you take alcohol?
Do you have any special dietary needs or restriction?
Are you being treated for substance abuse?
Have you ever been hospitalized in the last 3 years?
Are you taking any prescription medicines?
Have you any psychological problem?
Have you had all vaccination done?
Do You have any of these?
Physical disabilities?
Hearing disabilities?
Heart problems?
Epilepsy?
Diabetes?
Asthma?
Vision problems?
Muscle or joint problems?
Intestinal problems?
Eating Disorders?
I certify that the above information is correct and complete. I take full responsibilities for my medical, psychological and physical condition for the duration of my program with RIAES. In case of any emergency every effort will we made to contact the persons parents or concerned person, in the event they cannot we ewached, I hereby give permission to the physician selected by the program director of RIAES to hospitalize or to secure proper treatment, injection, surgery and anesthesia to me.