Volunteer Registration Form

Mohauwathuto Innovative Centre NPC

Professional Volunteer Programme: Social Workers, Psychology Students, Psychologists, Occupational Therapists, Speech Therapists, Counsellors, and Allied Health Professionals

1. Personal Information

Full Name *

Gender (optional)

Province & Municipality *

Contact Number *

Email Address *

2. Professional / Academic Background

Current Role *

Social Worker / Social Work Student Psychologist / Psychology Student Occupational Therapist / OT Student Speech Therapist / Speech Therapy Student Counsellor Other

Other (specify)

Institution / Employer *

Highest Qualification Completed *

HPCSA Number

SACSSP Number

OTASA / SASLHA / Other

Year of Study (if student)

3. Areas of Interest

School-based assessments (screening, psychosocial assessments, functional assessments) Clinic-based support (early identification, referrals, disability support) Research participation (data collection, interviews, observation, analysis) Community outreach (awareness campaigns, disability inclusion workshops) Programme facilitation (life skills, employability, creative/digital skills) Assistive technology support

Other (specify)

4. Skills and Competencies

Languages Spoken

Experience working with persons with disabilities

Specialised skills (e.g., AAC, behavioural support, sensory profiling)

Reasonable accommodation needs (if any)

5. Availability

Days Available *

Mon Tue Wed Thu Fri Sat

Times Available *

Morning Afternoon Full Day

Preferred Volunteering Duration *

6. Consent and Compliance

7. Emergency Contact

Full Name *

Relationship *

Contact Number *

8. Declaration

I, ____________________________________, declare that the information provided is true and correct. I understand the expectations of the Mohauwathuto Innovative Centre Professional Volunteer Programme and commit to upholding inclusive, ethical, and rights-based practice.

I, *

Signature *

Date *