BVSC · Web viewThurs 19th Sept Wed 18th Sept Fri 20th Sept Choice Sat 5th Oct Thurs 3rd Oct Fri 4th Oct Creation Thurs 17th Oct Thurs 10th Oct Fri 18th Oct Adaptation 6 hours of

APPLICATION FORM

Please return your Application Form by email or post to your regional contact using the contact details on the last page of this document by the deadline below:

DEADLINE: 12 NOON ON FRIDAY 9TH AUGUST 2013ABOUT YOU

Full name Known asDate of

birth Gender

Email address

Contact number

Postal address

Region London North East West Midlands

APPLICATION QUESTIONSPlease keep your answers to a couple of paragraphs and no more than 200 words per question.

Tell us about your proudest moment. What did you do and how did it feel?

Tell us about one of your aspirations for the future. How do you see yourself achieving this?

Tell us what you are passionate about.

What is the best way of contacting you? Phone call Email Text

How did you find out about this opportunity?

You don’t need to answer in writing (although you can if you want to), you can express your passion in a different way (e.g. song, video etc). Just make sure to send it along with your application form.

We have a limited number of fully funded places available. Please tell us why you should get this opportunity.

What support may you require from Changemakers to get the best out of the programme?

Are you able to attend all programme compulsory events? (See table below) Yes / No

COMPULSORY DATESMILESTONE LONDON BIRMINGHAM NEWCASTLE

Discover(Assessment Day) Wed 14th Aug Thurs 15th Aug Fri 16th Aug

Inspire Pre-Meet Friday 23rd Aug (5pm – 7pm)

Thursday 22nd Aug(time TBC)

Fri 23rd Aug (12pm – 2pm)

Inspire (Residential) Friday 30th August – Sunday 1st September

Aspire Sat 7th Sept Thurs 5th Sept Fri 6th Sept

Articulate Thurs 19th Sept Wed 18th Sept Fri 20th Sept

Choice Sat 5th Oct Thurs 3rd Oct Fri 4th Oct

Creation Thurs 17th Oct Thurs 10th Oct Fri 18th Oct

Adaptation 6 hours of flexible group support with your coach

Transformation Saturday 26th October

Graduation Saturday 2nd November

Participants MUST be able to attend all of the compulsory dates for their region.

RELEVANT ACTIVITIESPlease use this space to tell us about any relevant activities or experience you think may add to your application. This could be volunteering, paid or unpaid work experience, qualifications or courses you have undertaken, or anything else you think we might like to hear about. You may use more space if necessary.

Type of activity (e.g. voluntary, education,

work)Address of Activity

Dates from and to(DD/MM/YY)

Relevant information /

responsibilities

Type of activity (e.g. voluntary,

education, work)Address of Activity

Dates from and to(DD/MM/YY)

Relevant information /

responsibilities

MEDICAL AND DIETARY INFORMATIONName of doctor

Contact number

Postal address

Details of medical conditions, allergies, and prescribed medication

Details of allergies to any medication or treatment

Details of any special dietary requirements

Will the participant be bringing any prescribed medication to events? Yes (details: ) / No

Is there anything else you think we should be made aware of?

EMERGENCY CONTACTIn the event of an emergency please provide us with two individuals whom you would like us to contact. In the event of an emergency, we will attempt to contact the first person listed twice by phone, before contacting the second person. For those under 18, we will transfer responsibility for the child to either of the listed emergency contacts.

Full name Relationship to you

Contact number Emailaddress

Postal address

Full name Relationship to you

Contact number Emailaddress

Postal address

CONSENT FORM If you are UNDER 18 years old you MUST get a consenting adult to complete and sign this final section of the form. If you are over 18 you do not need to complete the next two sections but please read the agreement detailed on the following page and sign to confirm consent.

DETAILS OF CONSENTING ADULT

Full name Relationship

Contact number Email address

Postal address

EARLY RETURNS In the event the participant must be collected from a Changemakers event please supply the details of two adults whom Changemakers may release the participant to. The designated adults will have to provide photographic identification upon collection.

Full name Relationship

Contact number Email address

Full name Relationship

Contact number Email address

CONSENTThis is an agreement between Changemakers and the participant/consenting adult for the participant to take part in all Changemakers events and activities:

I (the participant/consenting adult) have read the supporting information and (agree to/agree to the participant) taking part in Changemakers events and activities.*

I (the participant/consenting adult) (agree to/agree to the participant) travelling on public transport unsupervised to attend Changemakers events and activities.

I (the participant/consenting adult) (agree to/agree to the participant) receiving medication as instructed and any emergency dental, medical, or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.

I (the participant/consenting adult) agree to photos and video footage of (myself/the participant) being taken during Changemakers events and activities which may be used for future promotional purposes by Changemakers including any printed materials and the Changemakers website, as well as any third party media who may be invited to events or activities.

I (the participant/consenting adult) understand that all who participate in Changemakers events and activities will sign up to a Code of Conduct. If participant’s behaviour breaches the Code of Conduct necessary disciplinary measures will be taken, and the participant may be asked to leave any Changemakers event or activity. In such instances any associated costs will be met by the participant.

I have read the document entitled ‘Consent and Personal Information’ which can be found at www.experiencechangemakers.org.uk or requested from Changemakers staff using the contact details on pg. 1.

I the participant/consenting adult understand and accept the details of consent outlined above Yes / No

Signed Date

Please note when completing this document electronically, by returning this document via the participants/consenting adults personal email address will serve as proof of consent and signature.

i The Code of Conduct is intended to be a reciprocal agreement between all participants and professionals attending Changemakers events and activities. It will usually cover things like the use of abusive language, racist, homophobic, sexist or violent behaviour. Changemakers will also not tolerate any damage to personal or public property, or behaviour that puts others at risk. Changemakers carries out through risk assessments for all events, activities, and venues that participants will be in. Any participant in possession of alcohol, or illegal drugs will have them confiscated and reported to the relevant authorities.

CONTACT DETAILS

Please return your application form to the contact within your region using the contact details below. If you are struggling with this application form or have any questions, please feel free to get in touch and we’d be more than happy to lend a hand.

London / Maria SykesChangemakers / 50 Scrutton Street / London / EC2A [email protected] / M: 07966 523 145 / T: 020 3078 9593

Birmingham / Ben HarnessChangemakers / St Georges Community Hub / Great Hampton Row / Birmingham / B19 [email protected] / M: 07785 611 799 / T: 0121 236 1313 

North East / Lizzie NixonChangemakers / Room 209 Holy Jesus Hospital / City Road / Newcastle upon Tyne / NE1 [email protected] / M: 07870 564 337 / T: 0191 233 3874