Teech Trip Application Form

TEECH Project 2012 Application Forms

If you would like to join TEECH on this years Project please complete the below forms together and send with a £50 deposit to secure your place on the trip Please note that the deposit is non-refundable and cheques or bankers drafts should be made payable to TEECH. You can now pay your deposit on-line at www.mydonate.bt.com/charities/teech just let me know when this has been made

ALL INFORMATION SUPPLIED WILL BE HELD IN THE STRICTEST CONFIDENCE Please complete this form and return to: Holly Field, 10 Halls Drift, Kesgrave, Ipswich, Suffolk IP5 2DE

. Please attach a photocopy of your passport details page when returning this form. . The minimum age of a volunteer is 16 years (supervision by a parent or guardian if under 18) . Volunteers are required to pay £450 towards their trip expenses and to raise a minimum of £200 in fundraising which goes towards the project costs of approx £20,000 e.g. transport of the lorries and equipment and supplies needed to be purchased for the project. Please note that gift aid is only collectable over and above the £450. . Flying is an option but flyers are expected to raise a minimum of £300 plus pay their air fare and any other transportation costs on top. . Please see the website www.teech.org for details on fundraising ideas and creating a personalised page with www.mydonate.bt.com this will help collect your donations electronically. . Volunteers are requested to attend at least one packing day at our storage facility Thorndon, Stoke Road, Suffolk IP23 7JG. . TEECH reserve the right to cancel your application at any time . Completed forms are confidential and some details e.g. home address, may be kept on a spreadsheet in electronic format, if you are not happy for this to happen, please tick this box  . TEECH sends e-mails to its volunteers with news and fundraising events and ideas and your details will be added to our mailing lists. If you do not want to receive these communications please tick this box  . Completion of this form does not guarantee a place on the next trip. . TEECH reserves the right to cancel your membership at any time and may not be able to refund any payments made.

PERSONAL INFORMATION Full Name Mr/Mrs/Miss/Other: First Name: Surname: Home Address

Contact Number Daytime: Evening: Mobile: Date of Birth E-mail address Next Of Kin or Name: Emerge Address: ncy Contact Contact No:

INOCULATIONS There are various inoculations, which are recommended for travelling to Moldova, please check this with

TEECH Is a charity registered in England, Registration number: 1074765 05/04/2018 Registered address: 1 Mandy Close, Ipswich, Suffolk, IP4 5JE England Page 1of Page 1 of 12 your doctor at your earliest convenience. It is your own responsibility to ensure you have the necessary inoculations for the trip. (please note, some inoculations need to be administered 3 months prior to the trip) ADDITIONAL INFORMATION

Please note that working insurance will be needed for ALL volunteers, NOT normal holiday cover, TEECH will acquire this insurance on your behalf. Do you have any criminal convictions or pending? If the project TEECH involves working with or around children, police checks may be required. Job Title & company name and address Registration No. of car if it’s to be left at one of BT depots (either Colchester or Ipswich TBC) , whilst you are on the trip GP’s Contact Details Name: Address:

Telephone no: Please ensure you have a current passport and that this does not expire within 6 months from date of travel. SKILLS INFORMATION Skills: Please categorise your skill levels below by marking an ‘x’ in the box below, where relevant. (This is of the utmost importance if we are able to assign responsibilities properly)

Key: 4 = qualified, 3 = highly skilled, 2 = some skills, 1 = carried out a few times Electrical  4  3  2  1 Carpentry  4  3  2  1 Plumbing  4  3  2  1 Bricklaying  4  3  2  1 General  4  3  2  1 Catering  4  3  2  1 DIY Plastering  4  3  2  1 Roofing  4  3  2  1 Spoken languages (including Signing):  4  3  2  1 Other (please state):  4  3  2  1 Please detail previous experience identified above with regards to decorating, plumbing, electrical, woodwork, building, cooking etc.

Please use an additional sheet of paper if you want to include a fuller description of your skills.

FIRST AIDERS Do you hold a current First Aid Yes/No certificate? (Proof of a current certificate will be required to carry out first aid)

Once your application has been processed you will receive confirmation by e-mail or post

Thanks

TEECH Trustee’s

TEECH Is a charity registered in England, Registration number: 1074765 05/04/2018 Registered address: 1 Mandy Close, Ipswich, Suffolk, IP4 5JE England Page 2of Page 2 of 12 TEECH Project 2012 Medical Form

. The questionnaire below MUST be completed in full. . Please complete honestly in order for TEECH to be able to recognise/deal with your condition, should the situation arise. . You must inform TEECH of any changes to the information contained within this document immediately . The information will be treated in strictest confidence . The completed form will be taken on the trip but kept in a sealed envelope in a secure environment, in case of an emergency. . If under medical care, please ensure that your Doctor is happy for you to take part in the project . If under medication, please ensure you have enough supplies with you and where possible inform a trustee of the application if necessary . TEECH reserve the right to cancel your application at any time should you be deemed to be suffering from a medical condition which could jeopardise your safety or others.

Name Mr/ Mrs/Miss: First Name: Surname:

Date of Birth

Address

Contact Number: Daytime: Evening: Mobile:

Have you visited a doctor for any reason at all during the last 12 months?

If yes, please give details:......

Do you have any allergies? (i.e. medicines, food, wasp stings)

If yes, please specify what and the reaction caused

......

TEECH Is a charity registered in England, Registration number: 1074765 05/04/2018 Registered address: 1 Mandy Close, Ipswich, Suffolk, IP4 5JE England Page 3of Page 3 of 12 Do you suffer, or have suffered from any of the following conditions. If the answer is 'Yes' please tick the appropriate box and give full details:

Name: Yes No If Yes, please give date and details

Heart Conditions:

Heart attack

Chest Complaints

Recurring headaches or migraine

Bronchitis/ Asthma / Emphysema

Abdominal Complaints:

Inflammatory/Irritable bowel disease

Dermatitis or other skin disorders

Peptic ulcer

Diabetes:

Diet Tablets Insulin (Please circle treatment)

Mental Health Problems:

Depression or similar

Stress or any forms of stress disorder

Blood Disorders:

Please state if not listed below

Haemophilia

DVT (clots in legs)

PE (clots in lung)

Nervous Disorders:

Blackouts, Epilepsy or Fits

Faints

Back Problems:

Sciatica

Slipped Disk

Arthritis

Serious Injury or Accident

TEECH Is a charity registered in England, Registration number: 1074765 05/04/2018 Registered address: 1 Mandy Close, Ipswich, Suffolk, IP4 5JE England Page 4of Page 4 of 12 Are you currently attending or awaiting an appointment at any hospital, clinic or out- patients department?

Are you currently attending a doctor?

Are you currently taking any medication?

Do you have a disability/medical condition? If so, it would be helpful to describe the nature of your disability. Please also tell us about any adjustments we could make to accommodate your disability/medical condition.

Any Other Illness/Condition which are not covered above:

Declaration

I declare to the best of my knowledge all the foregoing statements are correct.

Signature ......

Consent Form

Name ...... …......

Address ......

...... …………......

Date of Birth ...... …

If you are currently suffering from a medical condition or an ailment that may restrict your fitness, we may need a letter from your doctor to confirm that he/she is happy for you to participate in the trip.

In case of a medical emergency, I give my permission for Becki Taylor (qualified first aider) to authorise whatever treatment is deemed necessary or available, whilst abroad should I be incapacitated and incapable of making the decision for myself.

Signed:...... Date:......

TEECH Is a charity registered in England, Registration number: 1074765 05/04/2018 Registered address: 1 Mandy Close, Ipswich, Suffolk, IP4 5JE England Page 5of Page 5 of 12 Currency and Insurance

Currency

From past experience, the currency to take with you should not need to amount to more than £150, probably the best currency to take being Euros. This can be changed up for Forints (Hungary were we will stay overnight on our return trip) as required for when transiting through this country to and. Once we get to Moldova the currency is RON (Moldovan New Leu) please don’t be tempted to change it all up at once, as you probably won’t need it all. You will also need Euros to enable you to buy food and drink when we stop for rest breaks en route to and from Moldova as these are not paid for by TEECH, only the food whilst on location is provided. Probably about £20 worth of Hungarian Forints should be ample but it depends upon how much snack food you like to buy.

The current exchange rate for Moldovan New Leu (MDL) is 18.379 to the £1 and Hungarian Forints (HUF) 365.327 (as of 22/1/2012) but this is obviously subject to change. By all means bring a cash card with you as backup, but the charity cannot be held responsible should any mishaps occur such as fraud / theft so please do be extra vigilant.

Insurance to cover working abroad! This insurance is over and above the normal holiday travel insurance and will be arranged by TEECH (more detailed information about the insurance is covered in the Health and Safety Declaration). It will cover you to work abroad within certain guidelines. The cost of the insurance is covered by your £450 of trip expenses.

Code of Conduct for a TEECH Volunteer

TEECH Is a charity registered in England, Registration number: 1074765 05/04/2018 Registered address: 1 Mandy Close, Ipswich, Suffolk, IP4 5JE England Page 6of Page 6 of 12 Due to the nature of our work, we may come in close contact with vulnerable adults and children, consequently we must always be aware that seemingly innocent actions to us, may be wrongly interpreted by the local people. Therefore because of the way we operate and the impracticabilty of arranging CRB checks for all of our volunteers, it has been decided that the trustees would require that all volunteers sign and return a code of conduct agreement.

As a volunteer to this charity you would be expected:

 To act in a genuine, truthful and trustworthy manner at all times

 If you enjoy drinking alchohol – we realise that sometimes working in the conditions we have to, it can be very stressfull, so relaxing and enjoying an evening out can be so beneficial. What we do ask is that you avoid consumption of alchohol to an extent that it adversley affects your behaviour or the ability to fully participate in the project.

 Avoid any jokes and pranks that may be offensive to others – so please keep them safe and clean.

 Refrain from Lewd or rude behavior on route to or whilst at the project.

 Stay away from establishments where attendance might compromise the reputation of TEECH

This list is not exhaustive – please remember you are representing BT (our main sponsors), TEECH and our country

Thank you for your understanding in this matter!

Please sign and date below so this form can be kept on file

Name: ...... Signature: ......

Date: ......

Code of Conduct for a TEECH Volunteer

TEECH Is a charity registered in England, Registration number: 1074765 05/04/2018 Registered address: 1 Mandy Close, Ipswich, Suffolk, IP4 5JE England Page 7of Page 7 of 12 YOUR COPY – please sign and retain for your records

Due to the nature of our work, we may come in close contact with vulnerable adults and children, consequently we must always be aware that seemingly innocent actions to us, may be wrongly interpreted by the local people. Therefore because of the way we operate and the impracticabilty of arranging CRB checks for all of our volunteers, it has been decided that the trustees would require that all volunteers sign and return a code of conduct agreement.

As a volunteer to this charity you would be expected:

 To act in a genuine, truthful and trustworthy manner at all times

 If you enjoy drinking alchohol – we realise that sometimes working in the conditions we have to, it can be very stressfull, so relaxing and enjoying an evening out can be so beneficial. What we do ask is that you avoid consumption of alchohol to an extent that it adversley affects your behaviour or the ability to fully participate in the project.

 Avoid any jokes and pranks that may be offensive to others – so please keep them safe and clean.

 Refrain from Lewd or rude behavior on route to or whilst at the project.

 Stay away from establishments where attendance might compromise the reputation of TEECH

This list is not exhaustive – please remember you are representing BT (our main sponsors), TEECH and our country

Thank you for your understanding in this matter!

Please sign and date below so this form can be kept on file

Name: ...... Signature: ......

Date: ......

Health & Safety Declaration

TEECH Is a charity registered in England, Registration number: 1074765 05/04/2018 Registered address: 1 Mandy Close, Ipswich, Suffolk, IP4 5JE England Page 8of Page 8 of 12

To the Volunteers of TEECH 2012 Project

The Trustees of TEECH would like to make you all aware of the following before we depart on this year’s project to Moldova. “TEECH is run entirely on a voluntary basis by the Trustees listed at the bottom of this page The Trustees of TEECH are individuals who give their services free of charge and as such the Trustees do not accept any personal liability. You agree that the Trustees shall not be personally liable for the payment for any damages or for any breach of any legal obligations and the liability of TEECH and the Trustees shall be limited to the value of any assets of TEECH”

TEECH will take out Travel and Personal Accident insurance for those taking part in the aid trip. This cover is provided by Norwich Union and if you wish to obtain details of the cover please request these from our treasurer Robert Standley 07708 299159 ([email protected]). We believe that the cover is suitable and adequate but you are advised to verify this if you have any concerns.

We will try to make your project as safe as possible. A risk assessment will be carried out to minimise risk and steps will be taken to address issues arising.

You will find health and safely rules while out in Moldova will not be to the same standard as our own in the UK and it is easy to sustain an injury if you are not careful. Please be aware of safety at all times and work in a safe and responsible manner. You have a duty of care both for yourselves and others around you.

Hygiene standards are not easy to maintain when you are working in a messy environment with only limited washing facilities. Please take sensible precautions to avoid stomach upsets. For instance, do not handle food with dirty hands. Keep decorating equipment away from the food prep areas. Look after your well being by eating and drinking sensibly. Take enough rest breaks when working in hot conditions. Drink plenty of water!

To confirm that you have read and understood this letter, please sign both copies keep the personal copy for your own records but hand the TEECH copy to Holly.

I, the below, confirm that I have read the information pack in full regarding the trip taking place in August 2012. I understand the risks involved with volunteering for a trip such as this and I agree to abide by the code of conduct as laid down in the definition of a TEECH volunteer.

I also confirm that I have not been placed on the Sex offenders register.

Signed: ------Date: ------

Print Name: ------

YOUR COPY – please sign and retain for your record

TEECH Is a charity registered in England, Registration number: 1074765 05/04/2018 Registered address: 1 Mandy Close, Ipswich, Suffolk, IP4 5JE England Page 9of Page 9 of 12 Health & Safety Declaration