Personal Details Surname * Please enter your surname
Forenames * Please enter your first name
What type of project are you applying for? * Summer Project 3 Week Outreach Project Longer Commitment
Permanent Address Address 1 * Please enter an address Address 2 City * Please enter a city Postcode * Please enter postcode
Temporary Address Do you have a temporary address you need information sent to? (e.g University) Yes No
Address 1 Address 2 City Postcode
Phone Number * Please enter a phone number
Email Address * Please enter your email address
Date of birth * Please enter your date of birth
Place of birth * Please enter your place of birth
Nationality * Please enter your nationality
Do you have a passport? Yes No
Date of Expiry
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About you What are the main reasons for wanting to join the Lasallian Projects? * Please enter why you are applying
List any practical skills you might have * Please enter your skills
Hobbies, interests, pastimes * Please enter your hobbies
Do you have a Criminal Record? Yes No
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Health Working in a tropical/subtropical climate, particularly when it involves unaccustomed physical exertion, may exacerbate medical problems. Are there any medical conditions/disabilities which could limit the type of work or country that you might be involved with? Previous medical problems will not necessarily prevent you from taking part in a project. It is important that you complete the following to the best of your knowledge – any information given will remain confidential.
Have you ever suffered or are you suffering from any of the following? * Heart disease, Angina, High Blood Pressure, Circulation Disorders Hay fever or Asthma Frequent Sore Throats/ Sinusitis TB (tuberculosis)/ Haemoptysis Chronic Lung Conditions Ear Infections/ Deafness Epilepsy, Fits or Blackouts Migraine or Severe Headache Eye Conditions/ Visual Defects – not corrected by lenses Blood Disorders e.g. Anaemia, Sickle Cell, Thalassaemia Gynaecological Problems Dysentery/ Typhoid fever Severe Indigestion/ Peptic Ulcers Severe Neck/ Back Pain, Slipped Disc, Severe Arthritis, Bending or Lifting Problems Depression/ Anxiety, Mental Health Problems Diabetes Eating Disorders (Anorexia/Bulimia) Counselling/ Psychotherapy Substance Misuse Kidney/ Urinary Problems Hernia/ Varicose Veins Unplanned Weight Loss Splenectomy/ Immunity Problems or Long-term Steroid Treatment Foot/ Knee Problems Eczema/ Skin Problems Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE) or Anticoagulant Treatment Operations Disabilities Allergies to any Medications e.g. Penicillins NONE OF THE ABOVE Please select any applicable or none of the above
Are you a Smoker? If yes, how many cigarettes a week? * Please enter if you smoke or not
Do you drink alcohol? If yes, how many units per week? * Please enter if you drink
Do you take regular medication? * No Yes
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Do you have any other health problems? * No Yes
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Have you family suffered from any serious health conditions? * No Yes
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