.

NCS Application Form – Summer 2013

Personal Details

First Name
Middle Name(s)
Surname
Date of Birth / DD / MM / YYYY / Female / Male
House Name/Number
Street
Town 1
Town 2
Town 3
County / Postcode
Home Phone Number (inc. area code)
Mobile Phone Number
Email Address

For Office Use Only

Date Received:

Confirmed Yes / No:

CL Dispatch Date:

Parent/Guardian Details

First Name
Surname
Mobile Phone Number
E-mail

Place of Study/Work or Other Details

School/Organisation Name
Address 1
Address 2
Town/City / Post Code
Head Teacher Principal/Manager’s Name
Type of Study/Work (Mark box where applicable)
Studying GCSE’s
Studying for AS/A levels at sixth form or college
Studying for another qualification in a sixth form or college
Apprenticeship, similar type of training or work experience
Paid work (full-time or part-time)
Voluntary work
Look after home or the family
Stayed at home for another reason
Nothing
Don’t know
Do you participate in any voluntary activities outside of school? (Mark box where applicable)

No Yes, I have tried helping out or volunteering

Yes, I regularly help out or volunteer

Preferred Start Pattern

There will be three programmes running consecutively, giving you flexibility to fit your NCS around other commitments in the summer. Please indicate your availability by numbering each box in order of preference. We will do our best to start you on your preferred date(s), however, in the event of high demand this may not always be possible.

YMCA Lakeside Residential / Local
Residential / Local Daily Sessions / Preference
22nd – 26th July / 30th July – 2nd August / Week commencing:
5th August /
29th July – 2nd August / 6th – 9th August / Week commencing:
12th August /
5th – 9th August / 13th – 16th August / Week commencing:
19th August /

Key

1 = First choice, 2 = Second choice, 3 = Third choice, X = Unavailable

Friday 30th August 2013 – Graduation Day
I am able to attend the Graduation / I am unable to attend the Graduation

Declaration

Young Person:

Signed / Date


Monitoring Form

This information will be kept strictly confidential and used only for monitoring our recruitment and selection processes. It will only be shared with restricted access within the department.

Personal Details

Name: Date of Birth:
Gender (Mark box which is applicable)

Male Female
Ethnicity (Mark box which is applicable)
White British Irish
Traveller of Irish heritage Gypsy/Roma
Any other white background White and black Caribbean
White and black African White and Asian
Any other Asian Prefer not to say
Any other ethnic group
Religion (Mark box which is applicable)

Christian Buddist Hindu Sikh Muslim

Jewish Other Don’t know Prefer not to say
Do you consider yourself to have any disabilities? (Delete as applicable)
No Yes
If yes, please give further information below:
Free School Meals
Are you in receipt of free school meals? (Delete as applicable)
No Yes Don’t Know
Declaration
Signed…………………………………………………….. Date…………………

- 3 -