Wicked World Tours Travel Application Form You can fill in the form online, or download a printable version [Word, 271kb]. Before filling in the form, applicants are encouraged to read the accompanying Terms of the Award and Guidance for Applicants. We try to help cover the extra costs of travel faced by people with a disability. Name* First Last Date of birth* Address*Postcode*Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweTelephone numberEmail address* Name and Address of Refereee.g. teacher, youth worker, doctor, nurse, social workerWhat is your disability? Explain how it affects your travel plansi.e.what will cost you extra because of your disability? Purpose of travelIs it an adventure or educational?Where do you plan to go?How will you travel and what type of accommodation is planned?Who will be travelling, including any accompanying carers?Cost of travelPlease be as specific as you can at this stage.What is the extra cost because of your disability?Amount of grant you are asking from this trust, and how you will use itPlease be as detailed as possibleOther sources of funding applied for, and for how muchOther informationPlease use the following space to explain at greater length anything which you would particularly like the trustees to know: for instance, more about your reasons for the planned travel, why you consider it adventurous or about any special requirements you have because of your disability.PrivacyTo promote Wicked World Tours, your report (or a part of it) may be used in publicity. Please select one of the following choices.I give permission to use excerpts from my report, which may include my name and any photos submitted, for promotion of Wicked World Tours.I give permission to use excerpts of my report, but not my name or identifying photographs, as I prefer to remain anonymous.Declaration* I have read, understood and agreed to the terms and conditions EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.