FOOTBALL 4 PEACE INTERNATIONAL – I.C.E FORM

Please fill in and return via email to

While volunteering with us, we are responsible for your welfare and safeguarding all participants. Please ensure you enable us to support you by providing your details below. This form is confidential and will only be seen by the appropriate university / appointed staff and falls under University of Brighton data protection policies.

Your details:

Surname / Forenames
Title
(e.g. Mr / Miss Mrs / Dr / Prof) / Address:
E-mail
Contact Tel
Include country code
Place of Birth / Post Code
Date of Birth
DD/MM/YYYY / Country
Employer / Institution / Job Title / Course
Passport # / Issue Date
DD/MM/YYYY
Country of Issue / Expiry Date
DD/MM/YYYY
EU
Health Card # / Expiry Date
DD/MM/YYYY
Driver License # / Issue Date
DD/MM/YYYY
Country of Issue / Expiry Date
DD/MM/YYYY

Your Next of Kin’s details:

EMERGENCY CONTACT INFORMATION
Surname / Address:
Forename
Relationship / Post Code
Contact Tel
Include country code / Country

Your Doctor’s details:

Name / Address:
Contact Tel
Include country code
Fax
Include country code / Post Code
Country

All details will remain private and confidential. If your application is unsuccessful, this form will be destroyed.

Football 4 Peace International – University of Brighton (Charitable Status)

School of Sport of Service Management, University of Brighton. 1 Denton Road, Eastbourne, EAST SUSSEX. BN20 7SR.

E: T: +44(0)1273643777F:+44(0)1273643704 W:

Your relevant medical history:

Are you suffering from any of the following (please circle)?
Asthma or Bronchitis / YESNO / Allergies to unknown drugs / YESNO
Heart Condition / YESNO / Any other allergies (food etc) / YESNO
Fits, Fainting or Blackouts / YESNO / Other illness or disability / YESNO
Severe Headaches / YESNO / Back / knee / joint problem / YESNO
Diabetes / YESNO / Travel Sickness / YESNO
Any injury or break / YESNO / Other / Please give details below
If the answer to any of these question is YES, please give details below
Have you received vaccination against any Tetanus in the last 5 years(please circle)? / YESNO
Are you receiving medical or surgical treatment of any kind (please circle)? / YESNO
Have you been given specific medical advice to follow in emergencies(please circle)? / YESNO
If the answer to any question is YES, please give details below, including dosage of any medicines.
Do you have a registered disability (please circle)? / YESNO
If the answer to this question is YES, please give details belowincluding any adjustments that may be needed:

Diet Information:

Do you have any specific dietary needs (please circle)? / YESNO

Good Conduct Information:

Enhanced DBS Disclosure # / Issue Date
DD/MM/YYYY
Country of Issue / Company
Have you ever been convicted of a criminal offence?
Please disclose any details about any criminal convictions pending or spent below or in private with the Project Manager. F4Ppersonnel may be asked to undergo enhanced criminal record checks. Certain types of convictions will not affect applications. / YES / NO
REFEREE 1
Name / Address:
Organisation
Position
Contact Tel
Include country code / Post Code
E-mail / Country
REFEREE 2
Name / Address:
Organisation
Position
Contact Tel
Include country code / Post Code
E-mail / Country
I understand: that the information on this form will be shared with others on a need to know basis; that failure to disclose or withholding information may have serious consequences; that I must notify the university of changes in status regarding any disability or medical condition.
Sign: / Date:


TIER ONE COACH APPLICATION

Surname / Forenames

Before you proceed, you will need to know the costs involved in terms of your wallet and time commitment.

UK F4P / R4P Training Camp – 17-21Sepetmber 2016
Football or Rugby. You will be trained in the F4P methodology and receive an F4P tee, lunch and some evening hospitality is included. Choose which sporting code you will be taught in.
  • £250 online FEE - Fee balance deadline = 31 July 2016
  • £100DONATION - all fundraising must be completed by 31August 2016
/ Rugby
FOOTBALL
If additional accommodation is needed (which includes breakfast and dinner) please indicate this here. This will be at a cost of £125 in halls of residence (single en-suite in shared flats). / Accommodation?
If you are part of a current or former partner organisation or University of Brighton Alumni, please let us know in the box provided so we can apply the £50 discount. / Partner?

For your information – we have several opportunities where those trained can then put their skills into practice. Below is an indication of the costs involved and if you would like further information, please talk to us about joining the teams.

F4P / R4P Gambia – 8-22 december 2016
Football and Rugby. Assist in the delivery of a training camp to Gambian coaches and then working alongside them on a holiday camp for children. Includes study excursions. Development, poverty and empowerment context.
  • £650 online FEE – 1st payment (£175) deadline = 31 August 2016 / Fee balance deadline = 31 October 2016
  • £300 DONATION - all fundraising must be completed by 31 November 2016

F4p Ireland - April 2017 – dates to be confirmed
Football only. Delivering a training camp to Irish and Northern Irish coaches in the Republic and then working alongside Irish FA coaches on holiday camps across Northern Ireland. Includes study excursions. Co-existence and reconciliation context. Opportunity for further independent travel.
  • £200 online FEE – 1st payment (£75) deadline = 31 July 2016 / Fee balance deadline = 31 December 2016
  • £200DONATION - all fundraising must be completed by 31 March 2017

f4P Korea - July / August 2017 – dates to be confirmed
Delivering a training camp to Korean coaches in South Korea and then working alongside them on a festival for children. Includes study excursions and exclusive visit to DMZ / border with north. Peace education and reunification context. Opportunity for further independent travel.
  • £750 online FEE – 1st payment (£125) deadline = 31 July 2016 / Fee balance deadline = 31 January 2017
  • £400DONATION - all fundraising must be completed by 31 June 2017

  • First payments are non-refundable. No money is returnable after the final deadline as costs would have been incurred in your name.