welsh seventh-day adventist youth

Mission Trip August 2010

Summer School of English in Novi Sad

Name (please write your name as it appears on your passport):*

Gender*

Address*

Address 1

Address 2

City

State

Postal Code

Country

Email*

Date of birth*Use the calendar or enter the date using the format shown.

dd/mm/yyyy

Home telephone number**If you do not have a home number, please write "none"

Mobile telephone number*If you do not have a mobile number, please write "none"

Do you have any special dietary requirements?*(food intolerances only)

Are there any medical conditions/issues that we need to be aware of? **If YES, please give further details. Please include medications being taken or any allergies.

Do you have any experience of teaching English (or any other subject)?*Please give details.

In the unlikely event of an emergency, please tell us who you want us to contact:*

First

Last

Relationship of above person to you:*

Home phone number*Write "none" if the person doesn't have a home phone

Mobile phone number*Write "none" if the person doesn't have a mobile phone

Work phone numberIf they have one

Your G.P.'s name*

Your G.P.'s telephone number*

G.P.'s address:*

I agree to support all activities and to respect the philosophy of the Seventh-day Adventist Church whilst attending the Summer School in Novi Sad.*Please tick box to indicate you agree.

Yes

No

For parents of those under 18: I consent to my child going on this trip.Please tick box to indicate your consent.

Yes

No

Welsh Adventist Youth

Mission Project 2010 Application Form