Register for the Youth in Government Programme

Surname*
Forenames*
Home Address* (incl. Postcode)
Telephone No*
Mobile No
Email Address
Date of Birth*
Nationality*
Sex*	Male OR Female
Denomination* (Please Tick)	Catholic Presbyterian Methodist Church of Irelanf Other (please specify....

Do you suffer from any recurring ailments? (eg. Diabetes, asthma, epilepsy etc)

Are you disabled or require special requirements? If so, please describe

What are your hobbies and interests?*

Why do you want to be involved with the Youth in Government Programme? *

What do you think you can bring to the programme? *

What issues do you think are important to young people today? *

Are there any aspects of the programme (such as weekend residentials) which you may be unable to participate in?

Please give name and contact details of Teacher/Youth Leader who recommended this programme to you*

City of Belfast YMCA