Photo here. Read carefully before answering. Use print letters.. COUNTRIES. Period. Last Name. First Name. Personal Address. Telephone. Date of Birth (D/M/Y). Place of Birth. Nationality. Passport Number. Marital Status ___
Read carefully before answering. Use print letters.
Space to be filled out only by the Sending Committee
COUNTRIES
From
To
Period
20
–
20
From
To
Last Name
Male
Female
Male
First Name
Personal Address
Telephone
(+ ) -
E-mail
Date of Birth (D/M/Y)
Place of Birth
Nationality
Passport Number
Date of issue : Expiry date:
Marital Status ___________________________________
Person to contact in case of emergency (name, address, telephone, e-mail).
Please give details of your academic background and any previous or current work experience.
What is your mother tongue?
Do you speak any foreign languages?
Language
Years studied
Fluent
Good
Fair
Basic
What are your hobbies?
Please describe yourself, including your strengths and weaknesses.
Have you had any international experiences (for example: camps and conferences in other countries, contact with people of other cultures, etc.) ? If so, please give details.
Have you been involved in any organisations, movements, service programmes and other projects? If so, please give details.
What are your main reasons for going abroad?
Please indicate at least two choices of Voluntary Work Placement, in which you would you like to in the host country, and why?
1: _______________________________
Why:
2: _______________________________
Why:
What skills do you have?
Working with children/youth
Manual skills (please specify)
Working with disabled
Teaching
Working with elderly people
Sports
Computers
Music
Others, please specify
Do you have a driver’s licence/permit? If so, would you be willing to drive in a foreign country?
Yes No
Yes No
What do you hope to gain from and achieve during the exchange programme?
What challenges do you think you will encounter during your experience?
Do you have any objections to sharing a room?
Yes No
If your answer is yes, please explain why.
Do you smoke?
Yes No
Do you have special dietary requirements? Please indicate.
No
Vegetarian
Other
Do you have any allergies?
Yes No
If your answer is yes, please indicate what kind.
Do you have any medical/health issues that may affect your participation in the programme? Please include all details of any existing medical condition, of any medication you are currently taking and of any hospital treatment received in the past year.
HEALTH SIGNED DECLARATION / WAIVER
Although ICYE will provide me with a Travel Insurance coverage, it is my responsibility to check that I have all the necessary vaccinations required. ICYE cannot be held responsible if I do not get the appropriate vaccinations or if I do not mention any pre-existing medical conditions that affect the placement in anyway.
Date _____________________ Signature of Candidate __________________________________
Please feel free to complement this form providing additional information on a separate sheet of paper.
DATA PRIVACY DISCLAIMER
I agree that ICYE may collect, use and share my personal data as well as the data provided for third parties mentioned in this form (your emergency contact), with the following programme stakeholders: hosting organisation, host family, host placement, insurance company and the ICYE International Office.
In accordance with our data protection policy [available at http://www.icye.org/data-privacy/], your personal data will be securely stored and be kept indefinitely for statistical, bookkeeping and transparency reasons, but by no means for commercial or promotional purposes. If you do not want your data to be stored, please contact your sending organization.
If you would like your data to be deleted at the end of your contract/volunteering period, or at a later date, please inform/contact your sending organisation.
Please tick one of the following boxes: I consent I do not consent
Date_____________________ Signature of Candidate ____________________________
If selected to participate in the ICYE volunteering programme, I also agree that ICYE may collect and use my photos and articles on the website, on social media, in newsletters, etc. for promotional purposes.
Please tick one of the following boxes: I consent I do not consent
Date_____________________ Signature of Candidate ____________________________
