APPLICATION FORM
Please return your Application Form by email or post to your regional contact using the contact
details on the last page of this document by the deadline below:
DEADLINE: 12 NOON ON FRIDAY 9TH AUGUST 2013
ABOUT YOU
Full name
Date of
birth
Email
address
Postal
address
Region
What is the best way
of contacting you?
Known as
Gender
Contact
number
London
Phone call
North East
Email
West Midlands
Text
How did you find out about this
opportunity?
APPLICATION QUESTIONS
Please keep your answers to a couple of paragraphs and no more than 200 words per question.
Tell us about your proudest moment. What did you do and how did it feel?
Tell us about one of your aspirations for the future. How do you see yourself achieving
this?
Tell us what you are passionate about.
You don’t need to answer in writing (although you can if you want to), you can express your passion in a
different way (e.g. song, video etc). Just make sure to send it along with your application form.
We have a limited number of fully funded places available. Please tell us why you should
get this opportunity.
What support may you require from Changemakers to get the best out of the
programme?
Are you able to attend all programme compulsory events?
(See table below)
Yes / No
COMPULSORY DATES
Participants MUST be able to attend all of the compulsory dates for their region.
MILESTONE
LONDON
Discover
(Assessment Day)
Wed 14th Aug
Inspire Pre-Meet
Friday 23rd Aug (5pm –
7pm)
BIRMINGHAM
NEWCASTLE
Thurs 15th Aug
Fri 16th Aug
Thursday 22nd Aug
(time TBC)
Fri 23rd Aug (12pm –
2pm)
Friday 30th August – Sunday 1st September
Inspire (Residential)
Aspire
Sat 7th Sept
Thurs 5th Sept
Fri 6th Sept
Articulate
Thurs 19th Sept
Wed 18th Sept
Fri 20th Sept
Choice
Sat 5th Oct
Thurs 3rd Oct
Fri 4th Oct
Creation
Thurs 17th Oct
Thurs 10th Oct
Fri 18th Oct
Adaptation
6 hours of flexible group support with your coach
Transformation
Saturday 26th October
Graduation
Saturday 2nd November
RELEVANT ACTIVITIES
Please use this space to tell us about any relevant activities or experience you think may add to
your application. This could be volunteering, paid or unpaid work experience, qualifications or
courses you have undertaken, or anything else you think we might like to hear about. You may
use more space if necessary.
Type of activity (e.g.
voluntary, education,
work)
Address of Activity
Dates from and to
(DD/MM/YY)
Relevant
information /
responsibilities
Type of activity
(e.g. voluntary,
education, work)
Address of Activity
Dates from and to
(DD/MM/YY)
Relevant
information /
responsibilities
MEDICAL AND DIETARY INFORMATION
Name of
doctor
Postal
address
Details of medical conditions, allergies,
and prescribed medication
Contact
number
Details of allergies to any medication or
treatment
Details of any special dietary requirements
Will the participant be bringing any
prescribed medication to events?
Is there anything else you think we should
be made aware of?
Yes (details:
) / No
EMERGENCY CONTACT
In the event of an emergency please provide us with two individuals whom you would like us to
contact. In the event of an emergency, we will attempt to contact the first person listed twice by
phone, before contacting the second person. For those under 18, we will transfer responsibility for
the child to either of the listed emergency contacts.
Full name
Contact number
Relationship to
you
Email
address
Postal address
Full name
Contact number
Relationship to
you
Email
address
Postal address
CONSENT FORM
If you are UNDER 18 years old you MUST get a consenting adult to complete and sign this final
section of the form. If you are over 18 you do not need to complete the next two sections but
please read the agreement detailed on the following page and sign to confirm consent.
DETAILS OF CONSENTING ADULT
Full name
Relationship
Contact
number
Email address
Postal address
EARLY RETURNS
In the event the participant must be collected from a Changemakers event please supply the
details of two adults whom Changemakers may release the participant to. The designated adults
will have to provide photographic identification upon collection.
Full name
Relationship
Contact number
Email
address
Full name
Relationship
Contact number
Email
address
CONSENT
This is an agreement between Changemakers and the participant/consenting adult for the
participant to take part in all Changemakers events and activities:

I (the participant/consenting adult) have read the supporting information and (agree to/agree
to the participant) taking part in Changemakers events and activities.*

I (the participant/consenting adult) (agree to/agree to the participant) travelling on public
transport unsupervised to attend Changemakers events and activities.

I (the participant/consenting adult) (agree to/agree to the participant) receiving medication
as instructed and any emergency dental, medical, or surgical treatment, including
anaesthetic or blood transfusion, as considered necessary by the medical authorities
present.

I (the participant/consenting adult) agree to photos and video footage of (myself/the
participant) being taken during Changemakers events and activities which may be used for
future promotional purposes by Changemakers including any printed materials and the
Changemakers website, as well as any third party media who may be invited to events or
activities.

I (the participant/consenting adult) understand that all who participate in Changemakers
events and activities will sign up to a Code of Conduct. If participant’s behaviour breaches
the Code of Conduct necessary disciplinary measures will be taken, and the participant may
be asked to leave any Changemakers event or activity. In such instances any associated
costs will be met by the participant.

I have read the document entitled ‘Consent and Personal Information’ which can be found
at www.experiencechangemakers.org.uk or requested from Changemakers staff using the
contact details on pg. 1.
Please note when completing this document electronically, by returning this document via the
participants/consenting adults personal email address will serve as proof of consent and signature.
I the participant/consenting adult understand and accept
the details of consent outlined above
Signed
i
Yes / No
Date
The Code of Conduct is intended to be a reciprocal agreement between all participants and professionals attending
Changemakers events and activities. It will usually cover things like the use of abusive language, racist, homophobic,
sexist or violent behaviour. Changemakers will also not tolerate any damage to personal or public property, or
behaviour that puts others at risk. Changemakers carries out through risk assessments for all events, activities, and
venues that participants will be in. Any participant in possession of alcohol, or illegal drugs will have them confiscated
and reported to the relevant authorities.
CONTACT DETAILS
Please return your application form to the contact within your region using the contact details
below. If you are struggling with this application form or have any questions, please feel free to get
in touch and we’d be more than happy to lend a hand.
London / Maria Sykes
Changemakers / 50 Scrutton Street / London / EC2A 4XQ
Maria@changemakers.org.uk / M: 07966 523 145 / T: 020 3078 9593
Birmingham / Ben Harness
Changemakers / St Georges Community Hub / Great Hampton Row / Birmingham / B19 3JG
Ben@changemakers.org.uk / M: 07785 611 799 / T: 0121 236 1313
North East / Lizzie Nixon
Changemakers / Room 209 Holy Jesus Hospital / City Road / Newcastle upon Tyne / NE1 2AS
Elizabeth@changemakers.org.uk / M: 07870 564 337 / T: 0191 233 3874