Application for Ideals Zambia Project 2012

Name / University
Gender / Current Year of Study
Degree
Contact Telephone Number / Permanent Address
University Email Address / None University Email Address
Issue date of most recent CRB form
List relevant qualifications and workshops attended (in last 3 years) / Date
Why do you want to participate in the IDEALS Zambia programme?
Outline and explain your paid or voluntary coaching and overseas experience. Describe what you learnt from the experiences and how you think it will be helpful to you if selected as part of the IDEALS project.
Rank the following sports in order of coaching ability and preference. Briefly outline your level of competence and your previous experience in these sports: Football, Netball, Volleyball and Basketball
Please enter sport / Please enter level of experience
If you are successful in your application we would strongly recommend that you obtain as much training and experience as possible in the Four target sports.
Please can you outline how you would intend to do this?
Give examples in sport where you can evidence your ability to be both a leader and a team player.
What is the most courageous or adventurous thing you have ever done?
How will you use this experience to further your personal development and career plans?
Please tell us about fundraising ideas you have for your trip to Zambia?
Emergency Contact Details
Emergency Contact Name
Contact Telephone Number
Relationship to you
Second Emergency Contact Name
Contact Telephone Number
Relationship to you
Passport Details
Date of Birth
Nationality
Place of Birth
Passport Number
Place of Issue
Date of expiry
Medical Requirements
Do you have any special dietary requirements or allergies?
If so, please detail
Do you have any medical condition/disability of which the programme provider should be aware of?
If yes then please detail
Please list any prescribed medication that you are taking:
GP Details
Surgery Name
Doctors Name
Contact number
Please read the below information and sign your consent:
The University will use the information supplied in accordance with the Data Protection Act for administrative purposes.
If you are successful, your application form and emergency contact details will be passed on to UK Sport, Sport In Action and EduSport in Zambia.Your name and email address will be shared with Perfect Day Foundation and Friends of EduSport, the two UK-based charities that support the Zambian NGOs.
Throughout the Placements the media students shall be taking photos of students on placement.These photos will be used as promotional tools through a number of different media outlets including websites and publications, by all stakeholders involved in the project.
I agree that all information provided is true to the best of my knowledge and I will notify UK Sport if any of the details provided change before the end of my Ideals placement.
I give consent that my details can be shared as stated above.
I give consent that my photo may be taken and used in future promotional media
Signed :
Date:
Thanks you for your interest. Please submit this application to: ……………………………………….