Information Sheet

Please complete and sign this sheet. Send by fax or mail to office in St. Paul, MN. Costs: $125.00 for host, transportation and help in Vlad. Add $15.00 per day for room unless you are staying in a hotel. $15 a day for food at the church and where you live. $300 a month for room and board for long term volunteers. Costs can be given to Fr. Myron with American cash when you arrive.

Mary Mother of God Mission Society 1854 Jefferson Ave. St. Paul, MN 55105-1662

usoffice@vladmission.org   651-227-0208

Name_______________________________________________________                                                                                  StreetAddress_________________________________________________

City ________________ State __________Zip ___________

Home Phone __________ Work Phone ______________________

E-mail ______________________________________

My Passport No. ______________________________________ Exp. Date

Date of Birth ____________ Social Security No. ________________

Please list any health problems, special medications you must have, foods you cannot eat, or allergies:

Doctor’s Name ____________________ Phone _____________________

Health Insurance _________________Phone _________Client No. _____

Person to contact in case of an emergency________________________

Phone ___________Relationship to You ___________________________

Employer’sAddress:____________________________________________

Work Phone:_______________________Work Fax:___________________

Your Job(student/manager/salesman/etc.):___________________________

Please check all that you are willing to help us with:

____ Clean-up of planned construction site—removing lumber, brush, rocks, and debris

____ Fence construction—digging postholes, pouring concrete, placing pickets, etc.

____ Foundation preparation—pouring, reinforcing, smoothing, installation, etc.

____ Basic carpentry—house framing, roofing, window and door installation, etc.

____ Dry wall, taping, and interior work

____ Finish carpentry—window and door casings, baseboards, trim, hanging doors, etc.

____ Painting, staining, wallpapering, wall tiling, etc.

____ Roofing, guttering, exterior finish work

____ Cabinetry

____ Electrical, wiring, lighting, etc.

____ Plumbing

____ Flooring, tile, wood flooring, linoleum, carpet laying, etc.

____ Interior decorating, window treatments, color selections, etc.

____ Preparing garden sites, landscaping, etc.

____ Sewing, tailoring, teaching sewing skills

____ Helping with care of children in orphanage, assisting the Sisters with babies, toddlers, etc.

____ Assisting elderly, cleaning apartments, etc.

The information I have provided is true. I understand that my work assignments will be based on this information. I have read and understand all the notifications in this packet, including the nature of my accommodations and my responsibilities for travel arrangements within the United States. I understand. Therefore, I will not hold Mary Mother of God Mission Society, its personnel, volunteers, representatives, or instruments responsible for any injuries or losses I incur during this trip.

Signed__________________________________ Date________________