PROGRAM PARTICIPATION APPLICATION FORM

Full Name:
Date of Birth:
- -
Gender: Male Female
Nationality:
Place of Birth:
Address:
Phone:
Fax:
Email:
Marital Status:

Name and Residence of Spouse (if married):


Names/Ages of children under 18 years (if any):


Educational and Professional Background:

Year
Colleges Attended or Professional Bodies Related
Course or Programme Involved
Level Achieved
Grade Achieved

A summary of your state of health:


Details of any serious illness, injury or nervous or physical disabilities (if any):


Other Information:

Name and Address of sponsors for your training in London: (if applicable)

Indicate your Church or religious affiliation(s)
a. Past
b. Present

Please briefly describe all previous work experiences, including any Faith-related ministries or recognised voluntary services:

What is your intended academic or professional direction/Area of Interest?

How will your involvement in ICDS help you to achieve your career ambition?

Write a brief statement about yourself, including reasons why you are interested in the ICDS programme Indicate what goals and expectations you have for participating in it

Write about 600 words on the problems or challenges in your neighbourhood that are of concern to you - and for which purpose you seek to involve in the studies/programmes of ICDS

Give names and addresses of two (2) referees:
   
SIGNATURE:
(your Initials)
DATE:
   

 

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