Application Form for non-UK Participants

HOW TO USE THIS FORM

All questions should be answered and returned to Tim Yearsley by e-mail to

The deadline for applications is 23June 2018in order to ensure that there is enough time to request and receive your reference and allow you to go ahead and make travel arrangements. We will endeavour to process your application as soon as possible and will notify you by e-mail within 14 days whether you have been accepted on to the programme and will instruct you regarding payment (€125).

PERSONAL INFORMATION

Name / Date of birth
Email / Mobile number
Gender / Marital status
Nationality / Navigator ministry

HEALTH

This information will be held in strict confidence but we do require you to disclose any condition that may have a bearing on your suitability for involvement with us.

Do you have any health problems of which we ought to be aware (including any food or medication allergies, diabetes, epilepsy and heart conditions)?

If yes, please explain: ______

Do you have any disabilities of which we ought to be aware (including sight, hearing, mobility, special educational needs, or mental health)?

If yes, please explain: ______

Have you ever suffered from depression, eating disorders, extreme homesickness, anxiety attacks, claustrophobia or any other phobia or mental health issue that might impact your time on ESTP?

If yes, please give details: ______

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EMERGENCY CONTACT DETAILS

Please give details of two people we an contact in case of an emergency

Name / Relationship to you / Telephone (with country code)
First
Second

REFEREE DETAILS

We also require a personal reference to be provided. Ideally this should be your Navigator Representative but if not then a Church leader, tutor, work supervisor or someone responsible who knows you well will suffice. Please complete their details below and we will contact them direct to ask them if they have any reservations about you participating in this programme.

Referee Name: ______

Relationship to you: ______

E-mail address:______

Telephone:______

Signed: ______Date: ______

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