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Name: (Mr/Mrs/Ms)*
Address*
Phone: (Day)*
Phone: (Evening)
Date of Birth:
Place of Birth:
Occupation:
Please outline why you wish to become a youth leader:
Please give details of youth training / any previous experience / involvement in youth activity / clubs:
Do you suffer from any illness / disability / medical condition which may at times effect your ability to work with young people? If so please give details:
Referees:
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