APPLICATION FORM

MODULO DE PARTICIPAO

Vertigem APP

NOTA BEM: este modulo deve ser compilato esclusivamente en ingls!

Information about the volunteer

The information you are asked to provide will serve the purpose of identifying the most suitable hosting project for your possible experience abroad.
If you feel that the space provided for the answers is not sufficient, you can continue writing on additional pages (on which you will indicate the
question(s) number(s) youre answering) you will then attach to the Application Form. Thank you!

Family Name

Given Name(s)

Please attach a passport

size picture of yourself
HERE

3
(Street/Avenue/Square)

(Nr.)

Address
(Postal Code, Town, Province)

Fiscal Code

5
Home phone

Facsimile
E-mail

Mobile phone
6
7
8
9
10
0

Date of birth (dd-mm-yy)

Place of birth

Height (cm)

Weight (kg)

Nationality

Identity Document

Carta Identit / ID card

Fathers name

Date of birth (dd-mm-yy)

Mothers name

Date of birth (dd-mm-yy)

Nr.

11
Brothers (name)

Date of birth (dd-mm-yy)

Living at home?

Sisters (name)

Date of birth (dd-mm-yy)

Living at home?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

12
Tel.
Full familys address (if different from yours)
13
(name, address, telephone numbers)
14

Other persons living in your home

Family name

Given name(s)

Date of birth (dd-mm-yy)

Relationship

15

Page 1 of 6

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APPLICATION FORM

Vertigem APP

MODULO DE PARTICIPAO

Describe the home where you live

Describe the place where you live (town, city, village; is it an urban, rural, industrial area?; where is located?; population?)

What are your hobbies?

Have you completed your compulsory/basic education?

Si/Yes

No

a) / further studies. Which?

If yes, what have you been
doing since?
b) begin to work. Describe your job

looking for a job

Which foreign languages have you studied and how many years?
Foreign language

Years of studies

19
Foreign language

Which languages do you speak and/or understand (including your mother tongue)?
Language Spoken/Understood fluently

Page 2 of 6

Language Spoken/Understood sufficiently

Years of studies

20
9

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Describe your previous experiences in other Countries and your interaction with persons of different nationalities and cultures

Describe your future plans with reference to studies or occupation

22

Indicate your preferences among the following opportunities for your voluntary service period abroad
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socially useful services provided to: (please tick all that apply)

physically and/or mentally disable people

people involved with alcohol and/or drug abuse

childhood and/or youth

poor and/or homeless

women

refugees and/or minorities

issues related services: (please tick all that apply)

peace and/or peace education

ecology and/or environmental education

international issues
The people I prefer to work with are

24

number the different alternatives progressively,

indicating with 1 your first choice
children
youth
adults and/or elders
females
males
people from Countries different from yours
able bodied
disabled
The place where I prefer to work is

25

number the different alternatives progressively, indicating with 1 your first choice
outdoors

office

youth center

school

day care center

community

26

The place where I prefer to live is

number the different alternatives progressively, indicating with 1 your first choice
with a host family

live where I work

in the countryside

in town / near a town

If you indicated a host family, please describe any characteristic you would like:

If you indicated other alternatives, describe what your experiences are in this type of living situation:

The skills I have and could share are:

(please tick all that apply)

typing

working with computer

carpentry, construction

working with children

working with disabled

sports
(which ones?)

teaching
(what?)

others
(specify)
The skills I would like to learn during my experience abroad are:
(please tick all that apply)

typing

working with computer

carpentry, construction

working with children

working with disabled

sports
(which ones?)

teaching
(what?)

others
(specify)

What are your main reasons for going abroad? And why did you apply with the European Voluntary Service?

24

27

28

29

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What do you think you can achieve during your voluntary experience abroad?

Describe the organizations, movements, service programs and other projects in which you have participated
31

What volunteer work do you do or have you done? (If you do or did, indicate what)
32

Describe the most positive and the most negative aspect of your personality

33

Describe an experience that has had influence on your life

34

Describe briefly a national event that has had an impact on you. Explain why and in what way

35

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Describe briefly a international issue or event that has had an impact on you. Explain why and in what way

Which problems do you think you will encounter abroad, living in a different culture with different set of values?

37
35

Do you smoke?

Yes

No

Do you have any special dietary requirements?

Yes

No

38
39

If yes, specify
Do you have allergies?

Yes

No
40

If yes, specify
Add here any further information you think it could be useful
41

Place & Date

Place & Date

Signature of volunteer

Signature of the sending organizations person in

charge