Address Line 1
Address Line 2
Date of Birth
Contact Address Line 1
Contact Address Line 2
Please state why you have applied for this program?
In order to be entitled for the project, you must be able to answer ‘Yes’ to the following seven questions. If you are unsure of any of them, please call Islamic Help.
Will you be able to fundraise £5,000 two months prior to your scheduled deployment?
2. Do you have or are you eligible to have a UK passport?
If yes: Date of Issue
Date of expiry
3. Are you available for a 2 week overseas experience?
Please pick a deployment date for:
Are you currently a resident in UK?
5. Are you prepared to follow our project requirements?
6. Are you willing and able to provide two written references?
7. Are you willing to attend pre-departure briefing and residential workshops before and after you have returned?
Which of these best describes your ethnic origin?
AsianWhiteBlack / African / Caribbean / Black BritishBritish AsianMixed / Multiple ethnic groupsOther ethnic group
Do you consider yourself to have a major disability or illness?
Do you have any physical restrictions?
Have you ever had any serious or permanently unbearable illness?
Have you ever had any mental / nervous problems / anxiety?
Are you undergoing any kind of medical treatment (including taking pills or drugs)?
Do you have any allergies?
Do you have any dietary restrictions such as no fish, vegetarian etc?
If you have answered ‘Yes’ to any of the above, please give details (Continue on a separate sheet if necessary)
I confirm that I have understood the specific requirements about my level of fitness and confirm that the information provided on this form is true and an accurate description of my medical history and current medical status.
I confirm that if my medical condition changes before the Mission Possible deployment in any way I will notify Islamic Help and re-submit a revised and signed medical form. I agree that Islamic Help can use this information in relation to this deployment
In the event of illness or an accident on the trip I hereby give Islamic Help permission to initiate necessary medical treatment, either directly or via a medical proxy, and to immediately notify my next of kin in case of hospitalisation
Doctor's Address Line 1
Doctor's Address Line 2
Daytime Telephone Number
Have you ever been arrested, convicted or cautioned for any offence?
Have you ever been abroad before?
If you have answered ‘Yes’ to the above, please give details
Please state how you found out about the project
Islamic Help Terms and Conditions
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