APPLICATION FORM
MODULO DE PARTICIPAÇÃO
Vertigem APP
NOTA BEM: este modulo deve ser compilato esclusivamente en inglês!
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) you’re answering) you will then attach to the Application Form. Thank you!
1
2
Family Name
Given Name(s)
Please attach a passport
size picture of yourself
3
HERE
(Street/Avenue/Square)
(Nr.)
Address
(Postal Code, Town, Province)
4
5
Fiscal Code
Home phone
Facsimile
E-mail
Mobile phone
6
Date of birth (dd-mm-yy)
Place of birth
7
Height (cm)
Weight (kg)
8
Nationality
Identity Document
 Carta Identità / ID card
Nr.
9
10
0
Father’s name
Date of birth (dd-mm-yy)
Mother’s name
Date of birth (dd-mm-yy)
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 family’s 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
APPLICATION FORM
Vertigem APP
MODULO DE PARTICIPAÇÃO
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?
 Si/Yes
Have you completed your compulsory/basic education?
If yes, what have you been
doing since?

 No
a) / further studies. Which?
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
APPLICATION FORM
Vertigem APP
MODULO DE PARTICIPAÇÃO
21
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
socially useful services provided to: (please tick all that apply)
23

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
number the different alternatives progressively,
indicating with 1 your first choice
24
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
number the different alternatives progressively, indicating with 1 your first choice
25
Page 3 of 6
outdoors
office
youth center
school
day care center
community
APPLICATION FORM
Vertigem APP
MODULO DE PARTICIPAÇÃO
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)
27
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)
28
What are your main reasons for going abroad? And why did you apply with the European Voluntary Service?
29
Page 4 of 6
APPLICATION FORM
Vertigem APP
MODULO DE PARTICIPAÇÃO
30
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
Page 5 of 6
APPLICATION FORM
Vertigem APP
MODULO DE PARTICIPAÇÃO
36
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
 Yes
Do you have allergies?
 No
40
If yes, specify
Add here any further information you think it could be useful
41
Place & Date
Place & Date
Page 6 of 6
Signature of volunteer
Signature of the sending organization’s person in charge