This is an important part of your visit to Home & Life. Please provide the following information
and email it to Home & Life with your application. You must provide this before being accepted
by Home & Life as a volunteer.

*This is a printer-friendly page if you wish to have a printed copy now for signing & posting to Home & Life.
Alternatively, request Volunteers Reference & Checks Form for email return

HOME & LIFE VOLUNTEER PROGRAM
12/10 Moo 6 Tay Muang Sub-district, Thai Muang District,
Phang-Nga Province 82120 THAILAND
Tel.: +6676 453078 Mobile : +6681-9513237
E-mail : homelifethailand@yahoo.com http://www.homelifethailand.net

Volunteer Reference & Checks Form

Personal Information, including passport-type photo (insert below)

Full Name:

Address:



Home Phone:

Alternate Phone:

E-mail Address:

Birth Date:

Nationality:

Male / Female:

Passport Number:

Issuing country:

Visa Number/Type:

Education:

Occupation:

I, named above, certify that I have no police record of criminal behavior and have never been warned about my behavior or the
possibility of prosecution for any offence involving children, violence or dishonesty. I understand that any misleading or false
statement on this will be reported to the Thai police. I also understand that Home & Life has a primary duty to protect its children’s
welfare, happiness and safety and will make any checks it feels are necessary, including possibly contacting my national police.

Yes/ No

Referee to guarantee your good character and suitability to work with children

Full name of referee:

Address:



Email address (*Must have email address):

Relationship:

Nationality:

Home & Life will email this person or organization for a reference. A member of your family is suitable – or a similar organization that
has benefited from your volunteer work in the past. This is necessary because we do not know volunteers and they will live and work with
our children and staff. You will appreciate the need to make sure our children are safe from unsuitable adults and, when accepted,
you will share in this responsibility

If you have any questions please contact Home & Life.

12/10 Moo 6 Tay Muang Sub-district,
Thai Muang District, Phang-Nga Province 82120 THAILAND
Tel: +6676 453078 Mobile: +6681-9513237
Email: homelifethailand@yahoo.com
Http://www.homelifethailand.net

______________________ ______________________
Signature (Volunteer) Date