Safer Internet Day Application Form
Name *
Your answer
Date of Birth *
MM
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DD
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YYYY
Tel Number *
Your answer
Email Address *
Your answer
Home Address *
Your answer
Name of Parent/Guardian *
Your answer
Parent/Guardian Tel Number *
Your answer
School *
Your answer
School Address *
Your answer
School Principal *
Your answer
We recommend that you have a teacher to help you run a campaign. Please give the name of the teacher who will assist you. *
Your answer
Email address of nominated teacher *
Your answer
Provide details of any relevant experience you have with awareness raising in your school/community/youth group. (Please note experience does not have to be related to internet safety). *
Your answer
Tell us why you would like to become a Safer Internet Day Ambassador? (50-100 words) *
Your answer
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