Alliance Youth Works

Contact:
Alyn Jones

AYW Mourne
Life Adventure Centre
Cornmill Quay
Annalong
BT34 4QG

Tel: 028 437 67244

Email:
alynjones@alliance
youthworks.org.uk

Instructions

Please use this form to register as a counsellor for Camp Alliance. The cost is £70 and is payable via PayPal when you have completed the form.

If you have any problems with the process, please do not hesitate to get in touch immediately using the details on the right.

Camp Alliance Counsellor Registration

Details

* Full name
* Age
* Marital status
* Date of birth
* Permanent address
* Postcode
* Telephone #
Mobile #
* Email Address
Term-time address (if appropriate)
Term-time postcode
Education and Employment
If you are still in education, at what level of school/college?
What subjects are you studying?
Are you or have you been employed? Please give dates, company, job title and main duties. (include part-time/weekend employment, starting with the most recent)
Interests
* What do you do in your spare time? What are your hobbies and interests? Do you do any voluntary work?
Medical and Social
* How would you describe your general health?
* Have you any allergies?	Yes No
If yes, give details
* Are you diabetic?	Yes No
* Have you had any serious illnesses in the last three years?	Yes No
If yes, give details
* Do you intend to take prescribed medication while working with children or young people?	Yes No
If yes, give details
* Have you suffered from any depressive illness in the last five years?	Yes No
If yes, give details
* Do you have any psychological or physical conditions that you think we should know about?	Yes No
If yes, give details
* Are you vegetarian?	Yes No
* Do you have any special dietary requirements?	Yes No
If yes, give details
Declaration of offence
* Do you have any prosecutions or have you ever been convicted at a court or cautioned by the police for any offence?	Yes No
If yes, please provide details of all pending prosecutions, convictions, cautions or bind over orders. You should include, if possible, the offence, the approximate date of the court hearing and the court which dealt with the matter.
(You are advised that under the provisions of the Rehabilitation of Offenders (Exceptions) Order (NI) 1979, as ammended by the Rehabilitations of Offenders (Exceptions)(Amendment) Order (NI) 1987, you should declare all convictions, including 'spent' convictions)
References
References should not be requested from relatives.
Friend
* Name
* Telephone #
Clergy
* Name
* Telephone #
Professional i.e. work/education
* Name
* Telephone #
Church Involvement
Name of church
Denomination
Term-time
* Describe briefly the beinning and growth of your faith in Jesus Christ
* How do you live out your Christian faith in your present situation?
* How would you advise someone seeking to become a Christian?
T-Shirt Size
* Select T-Shirt size
Declaration
> I declare that all the above information is correct and true. > I agree to inform AYW if any of the above information changes after I have sent this form (e.g. health, criminal convictions). > I am in good health and believe I am able to carry out the tasks required of me. > I agree to respect the authority of the AYW leadership and any guidelines set down by them. > I will make myself available for the set training events, as far as is possible for me to do so.
* Please tick

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