Form

The Spark* Changemakers Program is an opportunity for passionate leaders and changemakers in disadvantaged communities between the ages of 18-35 to:

- Join a global network of world-class, highly effective grassroots changemakers turning the tide against poverty and disadvantage.

- Participate in a 4-day Changemakers Summit from Tuesday, the 4th of September to Friday the 7th of March 2012.

- Have the opportunity to access the Changemakers Fund - a grant program providing strategic support and funds to high impact projects begun by Spark* Changemakers.

We are looking for:

Clear leadership potential (Have you led in the past? Are you able to inspire others around a cause?
A demonstrated ability to make things happen! (We are looking for do-ers not just talkers! Tell us about what you have achieved in the past, how you have gotten things done in your academic, work or personal lives.)
Passion and commitment to creating positive social change in your community. (This is not just a personal development experience. We are looking for individuals who are committed to leading change in their community for the long-term)

IMPORTANT APPLICATION GUIDELINES:

The application must be completed by the applicant themselves. While you may ask for guidance and support from others, the form must reflect your ideas and your passion, expressed in your own words.

Remember: If your application is successful, you will be alongside 24 other exceptional changemakers. It will be very clear if you received extensive support on your application, and that won’t be fun for anyone!

I have read the above information.*

Yes No

Full Name*

First Name Last Name

E-mail*

Phone Number*

- Area Code Phone Number

Birth Date*

Month Day Year

Gender*

Female Male

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

What is your current occupation? Are you employed, unemployed, or studying? Please include brief details of the work or study you are undertaking.*

It is very important that you attend all 4 days of the summit. Can you confirm that you will be available to attend the entire duration of the summit from 4 September - 7 September 2012 (You will need to plan for a full day each day)*

Yes No

Will you need to make travel arrangements to attend the summit? (If no, please go on to section 2)*

Yes No

There is limited funding available to support the travel of individuals who reside outside the local area. If this applies to you, please detail the cost of your travel and stay at the summit below. Please be realistic with your costs as your application will be influenced by our ability to support your situation with the limited funding available.

Please list details of the 3 most recent and/or relevant work/volunteer positions you have held.

1. Employer:

Position held:

Dates held: