NAKURU ENVIRONMENTAL AND CONSERVATION TRUST (NECT)

VOLUNTEER/GAP YEAR/GRADUATE APPLICATION FORM

Please complete the form IN FULL and write clearly in BLOCK CAPITALS and return it with 1 Signed Passport Photo And £10 Non-Refundable Administration Fee To (You can download this form and fill it in on your computer before printing it or emailing it back to us):
Nakuru Environmental and Conservation Trust
(Cambridge Sub-committee)
C/O  Arjuna wholefoods
       12 Mill road
       Cambridge
       CB1 2AD

Surname: 				First Name:	
Address: 

					Postcode: 	
Tel: 					Mobile: 	
E-Mail: 	
Driving License: 								Yes/No 	
School / University Name & Address: 

					Postcode: 
Tel: 	
Date Of Leaving School/University: 	
DIET: (e.g. vegetarian, kosher) 	
Passport Information
(Details exactly as in passport)
Town of Birth: 				Passport number
Country of Birth: 			Country of Issue
Nationality: 				Date of Issue: 		/	/     
					Date of Expiry: 	/	/

IF UNDER 18 YEARS OLD YOU MUST HAVE PARENTAL CONSENT 
FAMILY INFORMATION/GUARDIAN:

Title (Mr, Mrs, Other) : 	Initials: 	Surname: 	
Address: 

						Postcode: 	
Tel: 						Mobile: 	
E-Mail: 	

OTHER PERSONAL INFORMATION: 

'A' Level Subjects/Higher: 	
Details Of University Offers/Employment Plans: 

Degree (If Applicable): 	

Health (Confidential):

List Any Medical Conditions That May Affect You Overseas (Example Allergies): 	
Have You Ever Suffered From: Asthma/Epilepsy/Diabetes			Yes/No 
If Yes Please Specify Which: 	
Have You Ever Had Back Trouble Or Chronic Joint Problems?		Yes/No 
If Yes Please Specify: 	
Have You Ever Suffered From A Heart Condition?				Yes/No 	
Do You Suffer From A Disability?						Yes/No 
If Yes Please Specify & What Attention Is Required? 	
Have You Ever Suffered From A Psychiatric Illness/Eating Disorders?	Yes/No 
If Yes Please Specify 	
Are You Unable To Take Immunisations Or Blood Transfusions?		Yes/No 
If Yes Please Specify: 	
Are You Able To Swim Unaided?						Yes/No 	
Would You Describe Your Fitness As: 
Very Good		Good		Fair		Poor 	
Are You Required To Take Any Drug Regularly Or Periodically? 		Yes/No 
If Yes Please Specify: 	

Referees	

Name & Address Of Two Referees Not Related To You: 
Referee 1: 				Referee 2: 

Position of responsibility held: 	Position of responsibility held:
	
Hobbies And Interests (Sports, Music, Drama Etc): 	
Achievements (Expeditions, Awards, Other?): 	
Name Of Person You Wish To Be Paired With (If Applicable): 	
Have You Been Convicted Of A Criminal Offence? 				Yes/No 
If “Yes” Please Specify Separately 	

Emergency Contact details
(Name and address of an emergency contact during your proposed trip)
Full Name:					Relationship:
Address:					Tel. No.:
						Mobile No.:
Town/City:
Postcode:					E-mail:

Next of Keen

Full Name:					Relationship:
Address:					Tel. No.:
						Mobile No.:
Town/City:
Postcode:					E-mail:

Reasons for Applying: 

	

Why Did You Choose The NECT? 

	

How Did You Hear About NECT? - Please Be As Specific As Possible 

	

Please tick the circle if you agree to the following   O
To the best of my knowledge, the information given on this form is correct, I believe I am medically fit enough to travel to the Kenya Trip.

Signed _______________________________________________________________

Date _________________________________________________________________