Embed Size (px)
DESCRIPTION
form
Citation preview
Vo lunte er Appl ic ation Fo rm
A. PERSONAL DATA
1. GENERAL INFORMATION
First Name: Au li a _ Last Name: Agu s t in
Date of Birth: Au gu s t 1 8 t h , 1 9 9 1 _ Occupation: E n gl is h T u t o r / U n d er gr a du at e S t u d en t
Citizenship: I n do n es ia Passport No:
Address: J al an K e m an g R T 0 0 9 R W 0 1 1 N o . 2 3 , K ali s ar i , P as ar R eb o , J a k ar t a T im u r
City: J ak ar t a _ Postal Code 1 3 7 9 0 _ Country: I n d o n e s i a
Phone Number; Home: +6 2 2 1 8 7 2 7 2 3 0 _ Work: _ Fax:
Mobile: +6 2 8 9 6 5 2 4 7 4 5 4 8 Email: au li a.a gu s t in @ s am po er n ae du c at io n .n et
Religious Affiliation (optional) Is lam
2. SPECIALIST
English Language TeachingHandicrafting (Crochet Stiches)Choir Singer (Soprano)Movie Making (Windows Movie Maker)Indonesian Traditional Dancing (Sirih Kuning dance)Drama (listed as the best drama actress in Drama Festival in SSE)
3. LIST OF QUALIFICATION (S) OBTAINED
Qualifications Year Obtained InstitutionSenior High School 2009 SMAN 39 JakartaHigher Intermediate English 2009 Lembaga Indonesia - AmerikaDifferentiated Instruction 2011 Sampoerna School of
EducationInternational Facilitator and Interpreter
2009-recent Educational ConferenceVolunteer for marginal children 2011 Jambore Sahabat Anak
B. VOLUNTEERING DETAIL
4. How did you learn about the Camillian Social Center Chiangrai?
I found the website from a search engine (Google), then I learned and spread this information to my colleagues
5. Reason for volunteering?I am an English Language Teacher candidate, but I am really interested to know more about the special need education. I get in touch with children intensively since I am also an English tutor for primary school students. Later on when I finish college, and I will work professionally as an English teacher, thus I may find disabled children cases in my class. For that, I really need to prepare myself for these cases I would face in the real situation. I am willing to learn from this kind of volunteerism. Besides that, I love children and I like to help them with my own way.
6. Please reconfirm your area of interest and talent.
My passion is to teach English to other people. Moreover, I am really interested in teaching English to children with special need cases. I like also to help others learn arts, such as: singing, Indonesian traditional dancing, and role playing. My skills and talent would be very beneficial for people out there.
7. Please fill the period of your volunteer availability:
Start date: (dd/mm/yy) 01 / 0 9 / 2 0 1 2 End date: (dd/mm/yy) 01 /10 /2 0 1 2
8. Please provide two references that we contact (excluding relatives and roommates)who have known you for more than two years.
1. Name: Arlin Pusparini _ Relationship: Colleague
Address: J alan Taman Cipinang no. 23 RT 002 RW 06, Jatinegara. _
City: J ak ar t a Postal Code: 1 3 420 Country I n d o n e s i a
Phone Number; Home: Work: Fax:
Mobile: + 6 2 85694779509 _ Email: [email protected] _
2. Name: Nurul Fitri Hadyani _ Relationship: Colleague
Address: J alan Kp. Raden RT 009 RW 007 No. 41, Pekayon, Pasar Rebo. _
City: J aka r ta Postal Code: 137 10 Country I n d o n es i a _
Phone Number; Home: Work: Fax:
Mobile: + 62 85693707031 _ Email: [email protected] _
9. Have you ever been convicted, plead no contest or plead quilty to a felony or misdemeanor?
Yes _ No √
Camillian Social Center Chiangrai reserves the right to request police clearance certificate.
Signature: _
Date: M a y 8 t h , 2 0 1 2
*** Please attach a 2.5 x 3 inch photo
