mpintshi REGISTRATION FORM

Personal Details

NAME

This is a required question

SURNAME

This is a required question

HOME ADDRESS

This is a required question

POSTAL CODE

Must be a number

This is a required question

CONTACT NUMBER:

Must be a number

This is a required question

You need to be between 18 and 25 years to be a mpintshi

Date Of Birth

HOW OLD ARE YOU?

Must be a number

This is a required question

ARE YOU MALE OR FEMALE?

FEMALE
MALE

This is a required question

OTHER (Specify)

This is a required question

mpintshi (Mp) Pledge

I hereby pledge to commit my service to loveLife for at least one year, I will try, by my actions, to be a positive influence on others I will allow myself to be guided by the loveLife team for my growth and effective implementation of the programme. I promise to remember to live by this pledge, I mean it, I will live and keep it.

Do you Agree

This is a required question

Additional Information

If you qualify, would you like to be considered for a gB position in future?

Yes
No
Do not qualify

This is a required question

Date