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Application Form For PROJECT SOUTH AMERICA 2006
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Full Name of Applicant
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_________________________________________________________________________
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Address
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_________________________________________________________________________
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_________________________________________________________________________
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_______________________
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Postcode
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________________________
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Telephone Number (
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_______________________
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Date of Birth
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_______/________/________
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Mobile Number
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_______________________
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Email Address
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________________________
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Passport No.
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_______________________
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Marital Status
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________________________
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What is your occupation? (in the case of students, please state your intended occupation)
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___________________________________________________________________________________________________
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Do you have any medical problems or are you taking medication regularly? Please give details below. (Having medical problems will not necessarily prejudice your application and all details will be kept strictly confidential.)
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___________________________________________________________________________________________________
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___________________________________________________________________________________________________
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Doctor’s Name _________________________________
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Doctor’s Telephone number (___________________
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Full Name of Next of Kin
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_________________________________________________________________________
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Relationship
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_________________________________________________________________________
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Address
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_________________________________________________________________________
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_________________________________________________________________________
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Postcode
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_______________________
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Telephone Number(
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_________________________
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Give details of your Minister and one other person who will act as a referee.
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Name of Home Church
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_______________________
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Name
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_________________________
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Name of Minister
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_______________________
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Address
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_________________________
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Address
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_______________________
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_________________________
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_______________________
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_________________________
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_______________________
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_________________________
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Postcode
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_______________________
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Postcode
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_________________________
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Telephone number (
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_______________________
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Telephone number (
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_________________________
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What are your academic qualifications?
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______________________________________________________________________________________________
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______________________________________________________________________________________________
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______________________________________________________________________________________________
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Give details of your involvement in your home Church or Christian Union.
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Why would you like to participate in Project South America 2006?
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________________________________________________________________________________________________
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________________________________________________________________________________________________
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Which skills do you feel may be of special value?
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In what ways do you feel you could make a contribution to the work?
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In what ways do you think the experience will be of benefit to you?
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________________________________________________________________________________________________
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________________________________________________________________________________________________
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Do you speak Spanish? If yes, how well? _______________________________________________________
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Declaration:
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I have read the brochure on Project South America 2006 and if accepted I am willing to participate fully in all aspects of preparation for the project and all aspects during the time in South America.
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Signed _____________________________________
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Date ________________________________________
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Please return this form to:
Joyce Clingan, 37 Meadow Farm, Garvary, Enniskillen, Co Fermanagh, BT74 4QS.
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To be received on or before Friday 16th September 2005
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