Mobile Evaluation Seminar

Application form

Mobile Evaluation Seminar

“Inclusion Train”

15^th-19^th of November 2015, Strasbourg, France

(Arrival 14^th & Departure 20^th November)

PARTICIPANT INFORMATION

NAME
SURNAME		MALE	FEMALE
DATE OF BIRTH
NATIONALITY
DIETARY REQUIREMENTS & SPECIAL NEEDS (food, disability, allergies, etc.)

HOME ADDRESS

HOUSE/FLAT NUMBER
STREET
CITY
POSTAL CODE
COUNTRY
MOBILE PHONE
EMAIL

PARTICIPANT’S ORGANISATION ADDRESS

Organisation name
Street
Postal code
City
Country
Telephone
E-mail
Website
Contact person

INVITATION LETTER NEEDED FOR VISA (IF APPLICABLE)

Date & place of birth
Passport number
Issued at (place)
Issued on (date)
Valid until
Address in passport (if different from home address)
Location of nearest French Embassy
Current occupation
	What is your motivation to take part in the evaluation meeting?
	What was the impact of the seminar/T4T/Study Session on you at personal/professional levels?
	What kind of local action did you implement on access to social rights for young people since your participation in the seminar/T4T/Study Session?

If you didn’t implement any local action, what were the reasons/which were the barriers?

Please take note of the following conditions that will apply if you are selected to take part in the evaluation meeting “Inclusion Train”:

I commit myself to participate in the whole process, including:

- To prepare myself carefully for the evaluation meeting;

- To take part in the full duration of the evaluation meeting;

- To participate in the whole evaluation process

I am aware that obtaining a health and a full travel insurance are my own responsibility and at my own expenses. I understand that the information provided on my special needs does not remove my own personal responsibility for ensuring my own health.

I authorise the teamers to publish, in whatever form and by whatever medium, including the Internet, the outcomes of the evaluation seminar “Inclusion Train” and the pictures taken during this activity.

Place: Date: Signature:

Дата добавления: 2015-11-04