Applications form


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НазваниеApplications form
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Applications FORM

Live your City

Youth Exchange about Time Banking

  • 22nd - 29th March, 2012 (6 days, excluding travel days)


Please complete this form in English. The information presents in this form will help the team understand about you, so please be as exhaustive as possible!


PERSONAL DATA




Name and current address of the participant

Family name




First name




Street address




Postcode




City




Region




Country




Telephone




Email







^ Personal details

Date of birth




Gender

 female

 male

Nationality










^ Special needs

Do you have any special needs (dietary needs, mobility problems, health care, etc.)?




^ Emergency contact

Please provide contact details of a person who can be contacted in case of an emergency.

Family name (Mr/Ms)




First name




Street address




Postcode




City




Region




Country




Telephone




Email







^ Language Abilities (Spoken)

1. English

 poor

 good

 very good

 excellent

2. Other: ………………………

 poor

 good

 very good

 excellent




Motivation

^ Why would you like to participate in this course?






Results

How do you think to put into practice all that you´ll learn during the course?





I agree that my personal data given in this application form may be made available to other participants.

I also accept as participation fee and 30% of my travel cost.

Thank you

Please return this application form to:

Before the 20 February 2012

Contact person: Natallia Yaskevich

Liga.lyvs@gmail.com

+37529 5094737


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