PERSONAL DETAILS` First name(s): Family name / Surname: Marital Status: Date of Birth: Nationality: Sex: Telephone Number: Email Which placement are you applying for? January 2014 April 2014 July 2014 October 2014 How did you hear about ICS? Are you applying to be a general volunteer or a Team leader? Are you willing to possibly be away from home for 10 weeks? Friend Youth or community Worker General Volunteer Church/ Public Event University or school Team Leader Internet Are you committed to on-going engagement with your local community when the programme is completed? What are you currently doing? What is your highest educational level? Primary Education Secondary Education Tertiary Education Will you require any additional support during the programme (for eg for a disability/ financial or emotional hardship)? If Yes, Please describe. How would you describe your level of English? Excellent High Medium Low What languages can you speak? (Please list other ) Zulu Afrikaans Other: Page 1 of 6
MOTIVATION Why do you want to volunteer on the ICS programme? Name at least three reasons (Answer in your own words with a 250 word limit): Why do you think you should be selected for your chosen ICS programme? No qualifications or skills are required to participate. We are interested in any motivations, circumstances, or interests that might make you a good candidate. (Answer in at least 100 words) What have you done to help others? Have you ever been involved in volunteer work both inside and outside of the community you live in? If Yes, please describe below.? How often? Please give a brief on your roles and responsibilities. Page 2 of 6
REFEREES Please give details of two people who can provide a reference for you. They should be able to tell us about your character and suitability for the programme. A pastor, youth worker, teacher or community leader should be one of your referees. The other can be anyone who has known you for a long time, such as a family friend.. Your referees should not be related to you. First Referee: Name: How do they know you? Telephone number: Email Second Referee: Name: How do they know you? Telephone number: Email FOR ALL APPLICANTS: ADDITIONAL PERSONAL INFORMATION ICS is committed to recruiting a diverse range of volunteers and as part of this commitment we monitor information to ensure we are inclusive of all. We would be grateful if you would answer the following questions. What religion, religious denomination or body do you belong to? Do you consider yourself to have a disability? Please give details Do you live with your parents/ family? Page 3 of 6
FOR ALL APPLICANTS: MEDICAL HISTORY If you are accepted for the chosen ICS programme you will need to complete a medical history form in order to be medically cleared. This is to ensure that any medical condition you may have can be managed on the programme and that we can provide the appropriate support for you. All data will be treated as confidential. If you answer 'yes' to any of the following questions, please give details: Have you ever had any major illness, operations or accidents? Please give details including dates: Have you ever suffered from any mental/physical health problems? Please give details including dates Do you have any objections or allergic reactions to specific medication or food? Please give details: Are you taking any type of medication, or have you taken any medication in the last two years? Please give details: Page 4 of 6
FOR THOSE APPLYING TO BE LEADERS PLEASE COMPLETE THIS SECTION: In order for us to check that we can use your skills in a team leader role, please give us details of your 3 most recent qualifications and your 2 most recent jobs. Please always start with the most recent. You will need to provide a minimum of one entry in each section. QUALIFICATIONS Qualification 1 Qualification 2 Name of qualification: Date attained: Subjects: Name of organisation/ school/ university: WORK EXPERIENCE Employment 1 Employment 2 Name of Organisation: Name of Line Manager Telephone Number/Email: Job title: Dates worked: Description of duties: Page 5 of 6
ADDITIONAL REFEREES FOR TEAM LEADERS Please give details of one person who knows you in an academic or work capacity and who can provide you with a reference. Your referees should not be related to you. They should be able to tell us about your skills, experience and leadership ability. Third Referee: Name: How do they know you? Telephone number: Email FOR ALL APPLICANTS: DECLARATION All of the disclosed information is, to my knowledge, true and accurate. I give my permission for the information provided to be used by Zoë-Life,my selected volunteer agency and International Citizen Service solely for the purpose of my application and all related communication. I declare that all the income related information I have provided on this form is true and correct. Where I am dependent on my parent / carer, they also confirm that this information is true and correct. By completing this form, you agree that International Citizen Service, Zoë-Life and Tearfund will store and process your data in accordance with the requirements of our Data Protection Policies, Privacy Policies and in keeping with the Data Protection Act, UK 1998. You agree that agencies may transfer your data as is necessary. We will hold any information you give us in order to contact you about your volunteering options. We would also like to keep you informed about the range of ways you can become involved with International Citizen Service and its participating agencies. Are you happy to receive this information? Are you happy to be contacted by email? Signed by (Name) On the Day of (month and year) Signature: Page 6 of 6