Application Form_Gender Equality
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Application form for youth exchange in Samobor, Croatia. Download the form, fill it and send back to: [email protected]: 9.10. at 12:00For all questions send mail to the same contact provided.
Transcript of Application Form_Gender Equality
Spoznaj sebe
Hrvatska kola Outward Bound
Outward Bound Croatia
1. COURSE PARTICULARS
NameYouth exchange Hear our voice, gender equality is the right choice
Date and place17.10. - 25.10.2015. Samobor, Croatia
2. PARTICIPANT'S PARTICULARS
First, last name
Date of birth, Age Sex
Passport number
Address
City, postal code
Country
Phone number
Facebook name (to add you in Facebook group of the project)
Occupation
T-shirt size (XS, S, M, L, XL, XXL)
3. CONTACT PERSON'S PARTICULARS
(In case of emergency)
First, last name
Address
Phone number
Relation to participant
4. MOTIVATION FOR THE EXCHANGE
Please answer each question, give true answers, specific to you. Consider, that based on your answers we can develop the program in a way that serves your needs.
General answers do not support.
What makes you interested in this exchange?(min. 50 words)
What personal skills do you want to practice and develop? (min. 50 words)
What results do you expect concerning your personal development? (min. 50 words)
What do you want to learn concerning the themes of the exchange? (min. 20 50 words)
In which areas of your life do you want to use what you learn here? (min. 50 words)
Questions, remarks, anything else you want to add:
Special diets and needs (vegetarian, religious diets, physical limitations):
_________________________________________________________
5. PARTICIPANT'S MEDICAL PROFILE
Do you have any of the following conditions?
Please answer YES Or NO.
If Yes please explain:YesNoExplanation
-Heart problems
-High blood pressure
-Asthma
-Other respiratory/lung problems?
-Difficulty breathing when excercising
-Chronic Cough
-Headaches
-Epilepsy
-Fainting
Do you have any of the following conditions?
Please answer YES Or NO.
If YES please explain: Yes No Explanation
-Diabetes
ALLERGIES to medicines/food/insects/?
If YES,
-Please describe your reaction.
-Have you had Anaphylaxis?
-Have you been hospitalized?
Have you been Hospitalized within the last 2 years?
Do you have bone or joint problems?
Do you have any skin diseases or sensitivities?
Please list any Medications and dosages if you use them
Have you recieved tuberculosis and/or typhoid fever vaccinations?
Have you received immunizations and Tetanus shot?
Please list date.
Do you have special dietary requirements or allergies to foods?
Do you have other health concerns?
..
Participants name
Signature
DateSEND APPLICATION TO: [email protected] till 9.10.2015. at 12:00.
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