NANYANG JUNIOR COLLEGE

International Service-Learning Expedition [2009]

Dali, Yunnan Province, China [29th Nov to 17th Dec.]

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APPLICATION FORM:

PARTICIPANT’S PARTICULARS [PART A]

Name as in NRIC/ Passport: NRIC:
Passport No:
Passport Expiry Date:

(Please underline surname & Block Letters) Date of Birth: Age:

Nationality: (Please indicate if you are a Date of Issue:
Singapore PR)

Gender: M/ F Race: Place of Issue:

Blood Group: Religion: Civic Class:

Name of Civic Tutor:
Home Address:

Home Tel: Mobile: Email:

Allergy: (Food & Medical) Food Restriction(s):

PARENT’S/ GUARDIAN’S PARTICULARS [PART B]

Name: Relationship:

NRIC: Nationality:

Home Address: (if different from above)

Home Tel: Mobile: Office:

Email:

IN CASE OF EMERGENCY: * We must be able to contact this person at this

number at all
times.

Name of person to contact Relationship:

: (Block Letter)
Contact No.* : (Home) Mobile:

International Service-Learning Expedition 1

Dali, Yunnan, China 2009
 NANYANG JUNIOR COLLEGE
Parents’ Consent Form

I, ___________________________________[name of parent / guardian*] give my consent to my

son / daughter / ward* ______________________________[name of student] of CT group
__________ to participate in the following activity.

Activity: International Service-Learning Expedition

Venue: Dali, Yunnan + Beijing
Duration: 19 days
Date(s): 29th Nov. to 17th Dec. 2009
[tentative dates – subject to changes e.g. availability of flight]
Costs: $1,200 [includes subsidy but subject to changes in availability of funds]
*please delete accordingly

I am fully aware that participation in this international service-Learning

expedition to Dali, Yunnan, China involves certain amount of risk. I acknowledge
that my child/ ward is participating in this International Service-Learning
Expedition voluntarily and with knowledge of these risks. Although the College
and the teacher[s]-in-charge will take every precautionary measure to ensure the
safety of my child/ ward; however, I understand that MOE, the College and the
teacher[s]-in-charge will not be held liable for any accident, injury or loss
sustained by my child/ ward during the activity.

Nature of Project:
1. To aid in the construction of biogas tanks in Dali community, Yunnan Province,
China
2. To raise environmental awareness – in Dali village & local primary school
3. To teach conversational English to local primary school students
4. To conduct cross-cultural exchanges/ sharing sessions with primary school & local
youths
5. To embark on a Learning Journey to LiJiang & Beijing – to better understand the
social/ political/ economical/ environmental aspects of China

___________________ _____________________________
Date Signature of parent / guardian

PART B:
International Service-Learning Expedition 2
Dali, Yunnan, China 2009
 NANYANG JUNIOR COLLEGE
Details of Leader/ Facilitator experience

Any Outdoor/ Expedition Experience

Relevant Skills [First Aid/ CPR/ Video-editing/ Photography etc…]

Type of Skill / Date of Attendance or Certification/ Date of Expiry [if any]
1
2
3
4
5
Previous & current service-learning/community service involvement/
volunteer experience, if any [please describe briefly]

Why are you interested in the International Service-Learning

Expedition?

International Service-Learning Expedition 3

Dali, Yunnan, China 2009
 NANYANG JUNIOR COLLEGE
[Please write a brief essay]

PART C:

1. L1R5: _________________
2. Class: _________________
3. Name of Civic Tutor: ____________________________________________________
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 NANYANG JUNIOR COLLEGE
4. Subject Combination:
No. Subjects: Name of Subject Tutor
1 H2
2 H2
3 H2
4 H2
5 H1 GP
6 H1 Mother Tongue:
7 H1

5. Tutor’s Recommendation:

Recommended:

Not recommended:

Comments:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Please indicate where applicable:

6. Are you involved in the Scholars’ Development Programme?

Yes No

7. CCA:

No. Name of CCA Name of CCA tutor Signature

1

NOTE:
• Please indicate if it is a student-initiated interest group & name of CCA
Advisor.
• Also indicate if you have any external commitments, CCA and others.

8. Type[s] / Level of CCA involvement:

• Please indicate if you intend to run for EXCO as well as participate in a CCA
overseas trip and when.
• And if you are involved in any sport CCA, please indicate whether you are a
school player or not.
__________________________________________________________________________________
__________________________________________________________________________________
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 NANYANG JUNIOR COLLEGE
__________________________________________________________________________________
__________________________________________________________________________________

Others:
9. Please indicate if you intend to join any other internationalisation
trips - e.g.
Geography/ Economic/ History trips etc.
__________________________________________________________________________________
__________________________________________________________________________________

Final Instructions:

Upon completion, please submit completed application form [hard copy]

to:
Miss Darrell: coordinator for International Service-Learning Teams
[China team]
Pigeon Hole: 90
Deadline: 25th Mar. 2009 [Term 2/ week 1/ Wed.]
However, I would strongly suggest that you do not wait till the 25th March but to
submit your application form asap, and hopefully before the end of Term
1.

Please note, incomplete and late forms will not be entertained.

Regarding
Interview Schedule/ Sessions:
• Applicants please take note of upcoming announcements on interview
sessions.
• Interviews will be scheduled on a 1st come 1st serve basis.
• And you can sign up for the interview slots made available outside
the staff room at the beginning of the next term.
• Interview sessions will begin on Mar. 23rd [Term 2/ week 2/ Mon.]

So do be pro-active and look out for the interview schedule and your
appointment.
Thank you.

International Service-Learning Expedition 6

Dali, Yunnan, China 2009