Full Name: First Name* Last Name* Date: Date* Address: Street Address* City* State* Zip* CountryUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDemocratic Republic of the CongoDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNagorno-KarabakhNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandTurkish Republic of Northern CyprusNorthern MarianaNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRepublic of the CongoRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSouth SudanSpainSri LankaSudanSurinameSvalbardeSwatiniSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTransnistria PridnestrovieTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsIsle of ManUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabwe* Phone: Country Code* Phone Number* Email: Email* City of Birth: * Date of Birth.: Date* Passport No. * Passport issue date: Date* Passport expiry date: Date* Passport issuing agent:* Note: If you don’t have a passport and you are booking a course in your country of residence, please submit your Driver's License number instead of your passport.
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.Signature: Signature* Date: Date*
SECTION YES OR NO
If YES, by Whom Type Here . and When? Type Here Type(s) of Learning Disability (if known): Type Here
22. Have you ever had any of the following:
If YES, What? Type Here
SECTION YES OR NO1. Have you had any problems learning in middle school or junior high? Yes No* 2. Do you have difficulty working from a test booklet to an answer sheet? Yes No* 3. Do you have difficulty or experience problems working with numbers in a column? Yes No* a test 4. Do you have trouble judging distances? Yes No* 5. Do any family members have learning problems? Yes No* 6. Have you had any problems learning in elementary school? Yes No* 7. Do you have difficulty or experience problems mixing mathematical signs (+/x)? Yes No* 8. Do you have difficulty or experience problems filling out forms? Yes No* 9. Do you experience problems or difficulty memorizing numbers? Yes No* 10. Do you have difficulty remembering how to spell simple words you know? Yes No* 11. Do you have difficulty or experience problems taking notes? Yes No* 12. Do you have trouble adding or subtracting small numbers in your head? Yes No* 13. Were you ever in a special program or given extra help in school? Yes No*
EDUCATION 14. Were you ever in special education classes in school? Yes No* 15. Have you ever been diagnosed or told you have Learning Disabilities? Yes No* If YES, by Whom . and When? . Type(s) of Learning Disability (if known): 16. Have you ever been diagnosed or told you have Learning Disabilities with or without hyperactivity? Yes No*
GLASSES 17. Do you need or wear glasses or contact lenses? Yes No* 18. Was your last vision test within the last two years? Yes No*
HEARING 19. Do you need or wear a hearing aid? Yes No* 20. Have you had your hearing tested in the last 12 months? Yes No*
SPEECH 21. Have you ever seen a speech or language therapist? Yes No*
MEDICAL/PHYSICAL 21. Have you ever had any of the following: • a lot of ear infections? Yes No* • a lot of sinus problems? Yes No* • high fevers that lasted a long time? Yes No* • diabetes (high blood sugar)? Yes No* • severe allergies? Yes No* • a lot of headaches or migraines? Yes No* • a head injury? Yes No* • convulsions or seizures? Yes No* • serious health problems? Yes No* 23. Are you taking any medication that affect the way you think, act, or feel? Yes No* If YES, What?
Signature: Signature* Date: Date* Please check below:Signed by Participant Signed by Parent/Guardian of Participant (If Participant Is under 18 years of age)*