If you wish to apply please complete this form in as much detail as possible
 

Please complete the application form as fully as you can.
Do call or email if you have any questions.

All fields marked with an asterix * require you to fill them in.

1. Personal Details

Surname                                                       *

Forenames (as shown on your passport)     *

Name as you would like to be known           *

Address

Address1                                                      *

Address 2

Town/City                                                     *

County                                                         *

Country                                                        *

Postcode                                                     *

Contact

Telephone                            *

Mobile (optional)      
               

 

Email                                    

 

Date of Birth                           *      
dd 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / mm 1 2 3 4 5 6 7 8 9 10 11 12 / 19 yy 93 92 91 90 89 88 87 86 85 84 83 82 81 80 79 78 77 76 75 74 73 72 71 70
 

Age at time of Departure        *

Parent/Guardian/Next of Kin

Full Name (including title)     *

 

Daytime tel number             *

Address1   *                  
         

 

Address line 2           
             

 

Town/City     *     
                   

 

County                         *
        

 

Country        *
  

                     

Postcode                     *
       

 

Relationship to you               *

 

Nationality

Nationality        *  
                  

2. Education

Name of Educational Institute

School/College/University        *


Address Line 1                        *

Address Line 2                         

Town*                                      

County*                                   

Postcode*                                

Tel Number                               

Name of Head of Sixth Form/tutor (if known)       

What qualifications have you already gained?

GCSE's

 

A levels

 

Degree

 

 

3. Employment History

List any paid jobs you have had (including job title and dates)

 

What are your plans after your year out?

Go to university yes no

Go in to a career yes no

Other (please state below) yes no

Other                                                                          
 

Can you speak another language? (please state)   
 

To what standard do you speak the language?       

 

4. Experience and Skills

What strengths and relevant experience can you offer? Eg childcare *

 

Please list interests, sports music etc and give details of any clubs and organisations that you belong to.*

 

Which continents, excluding Europe, have you visited?

Africa yes no

Asia yes no

Australasia yes no

North America yes no

South America yes no
 

5. Personal History

Have you any medical disorders? yes no

If yes please give details?

Are you taking any regular medication? yes no

If yes please give details?

Have you any allergies? yes no

If yes please give details?

Have you any dietary requirements? yes no

If yes please give details?

Have you a previous criminal record? yes no

If yes please give details?

Have you ever been CRB checked? yes no

If yes please give details? (Credit Reference Bureau)

 

7. Referee

Name

Title * Title Mr Mrs Miss Doctor Professor Mr and Mrs
 

First Name *
 

Surname *

Address

Address1 *
 

Address line 2
 

Town/City *
 

County
 

Country *
 

Postcode *

Contact

Email

 

 

 

Departure Month * Select Month January February March April May June July August September October November December

Departure Year * yyyy 2007 2008 2009 2010

Placement Length * Placement Length 1 month(s) 2 month(s) 3 month(s) 4 month(s) 5 month(s) 6 month(s)