PORTUGAL 08.09.2012 – 16.09.2012 PARTICIPANT APPLICATION PERSONAL DATA FIRST NAME : BIRTHDAY:
LAST NAME : GENDER:
FEMALE: MALE: PREFER NOT TO SPECIFY: NOTES:
NATIONALITY:
PHONE:
PASSPORT: POSTAL ADRESS:
COUNTRY OF RESIDENCE:
NEED VISA TO PORTUGAL? YES NO IF YES, PROVIDE DETAILS: SPECIAL NEEDS/LANGUAGE SKILLS YES: NO: VEGETARIAN: OTHER (PLEASE DESCRIBE): REQUIREMENTS: NOTHING YES (PLEASE REFER MEDICAL/PHYSICAL STORY AND SPECIAL RELEVANT: ASSISTANCE AND/OR MEDICATION NEEDS, OR OTHER):
SMOKER : FOOD: NO SPECIAL MEDICAL/PHYSICAL SPECIAL CONDITION (INCLUDING ALLERGIES, MEDICAL INTOLERANCES, DISEASES, MOBILITY, ETC.): LEVEL OF ENGLISH:
(1) BASIC:
(2) MEDIUM:
(3) GOOD:
(4) VERY GOOD:
OTHER SPECIAL NEEDS (INCLUDING ACCOMMODATION):
ORGANISATION DATA ORGANIZATION NAME : YOUR ROLE IN THE ORGANISATION: WEBSITE: E-MAIL:
PHONE:
(5) MOTHERTONGUE:
POSTAL ADRESS:
ORGANISATION SHORT DESCRIPTION:
AIMS, ACTIVITIES, TARGET GROUP(S),
(10 LINES MAX.)
PERSONAL BACKGROUND, EXPECTATIONS, MOTIVATION & FOLLOW-UP PLEASE EXPLAIN WHAT MOTIVATES YOU TO PARTICIPATE ON THIS TRAINING. (CONSIDER INCLUDING INFORMATION ABOUT
WHY YOU WANT TO PARTICIPATE ON AN ADVANCED LEVEL TRAINING ON THIS TOPIC)
PLEASE DESCRIBE YOUR PREVIOUS EXPERIENCE DEALING WITH YOUTH PARTICIPATION.
(INCLUDE REFERENCES LIKE LINKS, GOOD PRACTICES, ETC.)
WHAT DO YOU EXPECT FROM THIS TRAINING? PLEASE EXPLAIN HOW WILL THIS TRAINING HELP YOU IN THE FUTURE STEPS IN YOUR ORGANISATION AND/OR COMMUNITY.
WHAT KIND OF CONTRIBUTION
CAN YOU BRING TO THE GROUP?
ANY OTHER COMMENTS, QUESTIONS, INFORMATION OR IDEAS THAT YOU MIGHT WANT TO SHARE.
DECLARATION I, THE UNDERSIGNED, CONFIRM THE AUTHENTICITY OF THE DATA I PROVIDED IN THIS APPLICATION AND DECLARE MY FULL AVAILABILITY TO PARTICIPATE ON THIS TRAINING FROM 08/09/2011 TO 16/09/2011, IN PORTUGAL. I ALSO CONFIRM MY PERMISSION FOR THE PUBLICATION OF ANY CONTRIBUTIONS, PHOTOS, VIDEOS OR OTHER MEDIA GATHERED IN THE CONTEXT OF THIS PROJECT. DATE: PARTICIPANT SIGNATURE:
PLACE:
ONLY COMPLETELY FILLED APPLICATIONS WILL BE ACCEPTED!!!
SEND YOUR APPLICATION TO atypic@dinamo.pt UNTIL 26/04/2012, 23:00 CET. Page 2 of 2