PLEASE COMPLETE ALL SECTIONS BELOW Skills Gap Year APPLICATION FORM Skills Gap YearΔ SECTION ASTUDENT PERSONAL DETAILSFirst NameLast NameDate of BirthIdentity NumberGender Female MaleHome LanguageT-shirt Size Are you disabled in any of the following areas Communicating Hearing Seeing Walking Self-Care RememberingWhat is your highest qualification?Where did you hear about us?WebsiteSocial MediaReferralSTUDENT CONTACT DETAILSCellEmailPhysical AddressCodeCountry of citizenship/ permanent residenceEMERGENCY CONTACT (If different from parents/guardian below)NameSurnameCellRelationshipSECTION BOTHER DETAILS1. Are you currently, or have you in the past, suffered from or received treatment for a chronic or acute mental illness? Yes No2. Are you currently, or have you in the past, suffered from or received treatment or supportive services for alcohol or substance abuse/ addiction, eating disorder, gambling addiction, or the like? Yes No3. Do you have a criminal record? Have you ever been imprisoned and/ or received a formal warning? Yes NoIf you have answered ‘yes’ to any of the questions above, please provide us with a brief description below:MEDICAL DETAILS1. Do you have any physical and/or medical conditions? (For example, asthma, diabetes, epilepsy, etc.) Yes NoPlease list here:2. Do you have any heart, lung, or ear conditions? Yes NoPlease list here:3. Do you have any allergies? Yes NoPlease list here:4. Do you have any chronic medical conditions not listed above? Yes NoPlease list here:To support students and to better facilitate your learning, it is helpful to know if you have any specific/ additional needs, or physical or medical conditions we need to be aware of. Just Skills may wish to interview you further in order to ensure that you are suitably prepared to join this gap year. The information on this application form serves only to ensure that you are ready to engage in the gap year at this time and will be treated with the strictest confidence.SECTION CPARENT/GUARDIAN DETAILSTitleFirst NameLast NameCellEmailPhysical AddressCodePERSON/ BUSINESS/ TRUST RESPONSIBLE FOR ACCOUNTNameIdentity/ entity NumberCellEmailPhysical AddressCodeSubmit Form
