Youth Exchange about Time Banking

Applications FORM

Live your City

Youth Exchange about Time Banking

• 22^nd - 29^th 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

[e-mail]

[phone]

Дата добавления: 2015-11-04