Your contact details

We will need to contact you by email to send you further details relevant to your application.

About you

Pick Disability is defined by the Equality Act as: 'A physical or mental impairment, which has a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities. The disability could be physical, sensory or mental and must be expected to last for more than 12 months or for the rest of the life of the person affected.'

Emergency contact details

Emergency contact 1

This should be a responsible adult able to take important calls in case of an emergency. They must be available by phone for the duration of your programme.

Emergency contact 2

Please provide details for an individual who resides at a different address to that of your first emergency contact.

This should be a responsible adult able to take important calls in case of an emergency. They must be available by phone for the duration of your programme.

Deposit

To reserve a place on the programme, we require a non-refundable deposit as a first instalment which will count towards your fundraising target. The deposit is £50 for volunteers applying from within the UK. If you are unable to meet this target, please contact us – we will find an alternative way to support you to join the programme: +44 (0) 20 7183 1286 or email info@raleighinternational.org

The payment will not be processed until your application has been screened by our recruitment team and you have been selected for a place on programme. This will take place within three working days.

If you are not the named card holder, you must have the card holder's permission before entering their details and submitting this form.

If you have any queries, please contact us on +44 (0) 20 7183 1286 or email info@raleighinternational.org

Please enter in the format MM/YYYY