NANJING 2014 YOUTH OLYMPIC GAMES: 16 – 28 AUGUST 2014
YOUNG AMBASSADOR PROGRAMME APPLICATION FORM

Kindly complete this document in full.


Personal Information

Family Name (as in passport)
Given Name 1 (as in passport)
Given Name 2 (as in passport)
Maiden Name (if applicable)
Previous name (if you have legally changed your name, IE due to marriage)
Gender
Demographic (i.e. Asian, Black, White)

ID NumberDate of BirthDDMMYYYYNationality (as per passport)

Passport / South African
YES/NO / Other: (Please specify)

Passport NumberDate of IssueDDMMYYYYExpiry Date (Your passport must be valid for at least 6 months from date of the Games)DDMMYYYYCountry passport was issued

Country of Birth
City of Birth (i.e. Pretoria)
Permanent Residential Address (The current location you reside)
Country
Province
City
Postal Address
Postal Code:
Telephone number (incl. dialing code)
Cellphone number
Additional alternative number(s)
Fax number
Email address
Alternative email address
Do you have a valid visa for China? / YES / NO
Visa number (if applicable)
Do you have a disability? / YES / NO
Please indicate the class of disability
Wheelchair user / YES/NO
Next of Kin (Full Name)
Next of Kin contact number


CAREER INFORMATION

Highest Grade Passed
Are you currently studying? / Yes/No
If Yes, Year of Study (eg, 1st yr)
List all modules registered for
Name of Institution
Name of Head of Department
Contact numbers
Are you currently employed? / Yes/ No
If yes, Name of Employer
Name of Supervisor/Manager
Contact numbers


Have you been involved in any ambassadorial youth leadership duties/responsibilities?
If yes, please elaborate and highlight your involvement (where possible attach references):

______


Are you able to travel to Nanjing, China between 26 and 28 March for the YA Seminar and from 16 – 28 August 2014 for the Youth Olympic Games? Yes/ No (circle appropriate answer)
Provide a short motivation why you should be selected as the Youth Ambassador for Team South Africa to the the 2014 Nanjing Youth Olympic Games:

______
Applicant’s signature: ______
Date:______

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