Achiever Network Application Form

Please tell us about you:

Title

Title (if Other)

Forename

Surname

Preferred Name

Example: Kevin to Kev, Alexandra to Alex

If you would like to let us know your preferred pronouns, please do so here

Address Line 1

Address Line 2

Town

City/County

Postcode

Borough / District

Mobile Number

Home Number

Email Address

Date of Birth

Please use format dd/mm/yyyy

Education / Occupation

If Other, please state:

Name of Organisation:

Application Questions

Please specify how you are involved in Jack Petchey Foundation?

What did you win your award for?

Please describe your key strengths and weaknesses (minimum of five for each):

Strengths

Weaknesses

What strength, weakness, skill, or attribute would you like to improve? How will you know that you have improved?

What qualities, attributes, and skills do you have that make you a potential leader?

You could give some examples of how you have motivated others, influenced change, or made a difference to your community, school, youth group, etc.

How do you think the Achiever Network will help you to develop?
It is very important to us that members of the Achievers Network have a positive learning experience. Please tell us how you think taking part in this programme will help you.

Referee Details

Please provide details of who referred you to the Achiever Network:

Title

Title (if Other)

Forename

Surname

Organisation Name

Role

E.g. Teacher, Head of Year, Leader

Phone Number

Email Address

Address Line 1

Address Line 2

Town

City / County

Postcode

How do you know the young person?

Parent/Carer Details

Please provide details of your parent/carer (aged 18+):

Title

Title (if Other)

Forename

Surname

Preferred Name

Example: Kevin to Kev, Alexandra to Alex

Relationship to Applicant

Mobile Number

Home Number

Email Address

Address Line 1

Address Line 2

Town

City / County

Postcode

Emergency Contact Details

In the event that we cannot contact your parent/carer, please provide details of an emergency contact (aged 18+):

Title

Title (if Other)

Forename

Surname

Preferred Name

Example: Kevin to Kev, Alexandra to Alex

Relationship to Applicant

Mobile Number

Home Number

Email Address

Address Line 1

Address Line 2

Town

City / County

Postcode

Submit Application

Please note that if you are under 18, you must get permission from your parent/carer to participate in the Achievers Network.

If you are under 18, we will send a copy of your application to your parent/carer and ask them to confirm that they are happy for you to participate.

We will also contact your reference.

Please note that the dates of the training days are as follows;

Selection Day - 21st September

Residential 18th-20th October

Training Day 1 - 30th November

Training Day 2 - 18th January

Training Day 3 - 8th march

Training Day 4 - 3rd may

Training Day 5 - 28th June