*(denotes required field)

Department to Contact: *

Select Webmaster Designer

First Name: *

Last Name: *

E-Mail Address: *

Preferred Name (i.e. Dan instead of Daniel)

Contact Number (Personal Mobile) *

Contact Number (Home Phone) *

Contact Number (Work Phone) *

House Number/Name *

Address Line 1 *

Address Line 2

Town/City *

County *

Postcode *

Date of Birth *

Sex: *

Male Female

Business Details:

UIN *

OUC *

Year joined BT *

Job Role *

Current Status in BT: *

Apprentice Graduate Other

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BT Line of Business: *

Global Services
Group
Innovate & Design
Openreach
Operate
Retail
Wholesale

Manager's Name *

Manager's e-mail Address (for sign-off and to initiate special leave clearance) *

Medical/Dietary Details

Preliminary Medical Details

A more detailed pre-expedition questionaire may require completion prior to confirmation of your place. Any information supplied is entirely confidential. Please answer as honestly and accurately as possible. Your responses will help the Challenge Worldwide Team at Giraffe Events advise the local medical team in the event of any emergency arising from a pre-existing condition.

Have you ever or do you suffer from:

Altitude Sickness
Migraines or Headaches
Asthma
Diabetes
Eczema Dermatitis or other skin conditions
High Blood Pressure
Heart Problems

If you said yes to any of the above, please provide details here:

Have you broken any bones or had an operation requiring anesthetic in the past 24 months? Please Detail: *

Are you at present on any GP prescribed medication or treatment? Please detail: *

Are you able to walk unaided (without the help of a stick) across uneven ground? *

Are you a smoker? (If yes please detail average number of cigarettes smoke each day) *

What is your height (without shoes)? Please provide your answer in both metric and imperial measurements *

What is your weight? Please provide your answer in both metric and imperial measurements *

What is your shoe size? (UK) *

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What is your T-shirt size: *

Small
Medium
Large
X-Large

Dietary Details

We aim to accommodate your preferences but this cannot be guaranteed in some of the remote locations we travel to.

What do you not eat?:

Red Meat - please detail below
Poultry - please detail below
Fish
Shell-Fish
Eggs
Cheese
Gluten
Milk
Nuts - please detail below
Other

If other, please Detail:

Fitness Assessment

How would you describe your current fitness levels? *

Have you any trekking experience? (if yes, please detail) *

Can you swim? *

Do you play any sports on a regular basis? (please detail) *

Are you prepared to achieve a good level of fitness (advice will be given) prior to this trip? *

Passport Details

Name (exactly as it appears on your passport) *

Nationality *

Passport Number *

Passport place of issue *

Passport date of issue *

Passport expiry date *

Place of birth *

I do not own a passport OR a passport with an expiry date AFTER MAY 2013 - I commit to apply for a new passport in good time and will supply full details in due course

Emergency Contact

Name *

Mobile Phone (if applicable)

Alternative Phone (i.e. evening land line)

Relationship of this person to yourself (i.e. mother, brother, spouse etc.) *

House Number/Name *

Address Line 1 *

Address Line 2

Town/City *

County *

Postcode *

Part 2

Application Assessment Questions

Community Experience

In 200 words please state what you have achieved either as part of the community or with BT to enhance or support the lives of people who are less fortunate than yourself*

Include any involvement you may have in any community groups outside of the workplace and what role you have played.

*If, for any reason you have difficulty in answering this question i.e. you have not had an opportunity to take part in any community projects to date – please contact lara@giraffeevents.co.uk for clarification and alternative ways in which we can judge your potential.

Answer *

What do you feel that you could contribute to this program, by way of personal strengths and abilities?

Answer *

What do you hope to gain from this experience and how will you apply it in the work place on your return?

Answer *

This event contains a variety of building blocks; the community and cultural interaction are just one element. Which elements of the proposed content for CHALLENGE 2012 attracts you most?

Does anything ‘jump off the page’ at this stage?

Answer *

Part 3

Personal Declaration

Terms & Conditions can be found in the Terms & Conditions section (left-hand menu).

I understand that if my application is succesful:

I have read understood and agree to be legally bound by the General Terms & Conditions (available in the left hand menu bar) regarding payment & donation deadlines and cancellations and health & safety and other essential event elements. *

I am up to date with all my Apprentice milestones / Training Plan objectives. *

I understand that failure to disclose relevant information or giving false information on the application form may result in termination of my place with no refund. *

I understand that BT Challenge Tanzania 2012 is a personal and proffessional training programme (ABSOLUTELY NOT A HOLIDAY!) which enables me to use a CSR model to significantly help impoverished communities whilst developing my own skill-set. *

I declare that to the best of my knowledge the information I have given is correct. *

I understand that, IN THE EVENT OF MY APPLICATION BEING SUCCESFUL, I will:

pay a nonrefundable personal deposit & registration fee of £500 payable to Giraffe Events Ltd in full or in 5 x equal installments as outlined in the General Terms & Conditions. *

fundraise a seperate and minimum sum of £3500 to cover the costs of the programme and travel and project materials. *

honour all contract payment and donation guideline dates as detailed in the Contract Terms & Conditions and the Programme Overview. *

Attend a briefing and fundraising strategy day on Monday 30th April and any subsequent training and preparation days. *

Keep in regular contact with my assigned Team Leader and/or Fundraising Mentor to keep my fundraising activity updated. *

agree to take out appropriate medical travel and cancellation insurance and provide a copy of the policy to the programme organiser (Giraffe Events). *

arrange to have a Yellow Fever Vaccination (certificate to be shown at Border Control in Tanzania) at my own expense and undertake any other advised inocculations or medication as prescribed by my GP. *

Agree to observe local customs dress and behaviour norms with sensitivity. *

Part 4

Gift Aid

Conditions of making a Gift Aid Declaration

You must pay an amount of Income Tax and/or Capital Gains Tax for each Tax Year (6th April one year to 5th April the next) that is at least equal to the amount of Tax that the Charity will reclaim on your gifts for that Tax Year.

Please notify Challenge Worldwide: Training for Life if you:

• Want to cancel this declaration
• Change your name or home address
• No longer pay sufficient tax on your income and/or capital gains

Tax claimed by the charity

• Challenge Worldwide: Training for Life will reclaim 28p of tax on every £1 you gave up to 5th April 2008
• Challenge Worldwide: Training for Life will reclaim 25p of tax on every £1 you gave on or after 6th April 2008
• The Government will pay to Challenge Worldwide: Training for Life an additional 3p on every £1 you gave between 6th April 2008 and 5th April 2011. This Transitional Relief for the charity does not affect your personal tax position

If you pay Income Tax at the higher rate you must include all your Gift Aid donations on your Self-Assessment Tax Return if you want to receive the additional Tax relief due to you.

Yes I am a UK Tax Payer

And I would like Challenge Worldwide: Training for Life to treat all donations I have made for the four years prior to this year and all donations I make in the future as Gift Aid donations until I notify you otherwise.

No I am not a UK Tax Payer

Part 5

Misc Information

I would prefer to travel on the following dates: *

Group 1: Proposed Dates Friday 02 November - Sunday 18 November 2012 (Thursday 14 November if opting out of the Beach Retreat extension)

Group 1: Proposed Dates Friday 16 November - Sunday 02 December 2012 (Thursday 30 November if opting out of the Beach Retreat extension)

I have no preference with regards to group or date of travel

I do not wish to participate in the Beach Retreat Extension. I understand that this will also reduce my personal deposit commitment from £500 to £300

Where did you hear about us?

How did you find out about this year's BT Challenge Worldwide programme? (Please tick all that apply) *

BT Today
TAN Newsletter
TAN Website
Gradnet
From my Manager
From my Apprentice Coach
From a previous 'Challengee'
Other

If other, please detail: