Please note that completing an application form does not commit you to a placement. When we receive your application we will send you further information and contact you to take your placement forward.
Personal Details First name * Surname * Date of Birth * DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC YYYY 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 Gender * Male Female Nationality * Occupation Contact Details e-mail Phone * Mobile Best time to call Address *     Postcode Country Next of Kin Name Relationship Phone Address     Postcode Country Medical Details * Any dietary requirements? * No Yes if Yes please specify Any medication? * No Yes if Yes please specify Any current / past illnesses or disabilities? * No Yes if Yes please specify	When would you like your placement? -- month -- January February March April May June July August September October November December -- year-- 2009 2010 2011 2012 If you have specific dates / range of dates, please specify For how long would you like a placement? -- Please select -- Weeks Month Which country / placement are you applying for? Belize -- Please select -- Reef Conservation Belize Zoo Cambodia -- Please select -- Bear Rescue Orphanage Nepal -- Please select -- Teaching Child Care Peru -- Please select -- Teaching Orphanage / care home Jungle Conservation project South Africa -- Please select -- African wildlife conservation Cheetah re-introduction Football coaching Horse rehabilitation Primate rescue Surf volunteering Tanzania -- Please select -- Teaching Building Charity Summer Camp Other roles If Other roles – please specify below: Thailand -- Please select -- Disabled school Dog and Cat care Elephant care Land conservation Marine Conservation Orphanage Summer English Camps Teach English anywhere Teach English on Koh Phangan Teaching Assistant Bangkok Teaching Burmese centre Wildlife Rescue Vietnam -- Please select -- Street children / orphan school Sapa hill-tribe community camp Summer rural community camp If you want to apply for a combination of projects in one country / multiple countries please describe below Applying with friends / partner If you are applying with a friend or partner please type their name(s) in the box below
Please use this section to tell us about:	(MS-Word or PDF)
Yourself and your interests Why you want to do this placement What you expect to give to the placement What you expect from the placement Feel free to type your answers into a separate document and attach by clicking on the browse button
Please use this section to let us know:
What travel you have done before Any relevant experience you have (including any qualifications) Any other information you think we should know Feel free to type your answers into a separate document and attach by clicking on the browse button
Where did you hear about PoD?
Internet search engine main listings e.g. Google Google sponsored link (box on side of Google page) gapyear.com responsibletravel.com	Newspaper / Magazine advert (please specify) Personal recommendation (please specify who) Other (please specify)
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