Application form

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Назва	Application form
Дата конвертації	01.11.2013
Розмір	21.67 Kb.
Тип	Документы

Application form

Answers in the Mirror

12 – 18 September 2013, Ankara,Turkey

(Arrival on the 12^nd- Departure on the 18^th)

PARTICIPANT INFORMATION

NAME
SURNAME	MALE	FEMALE
DATE OF BIRTH
NATIONALITY
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

PLEASE DESCRIBE YOUR WORK OR RESPONSIBILITY IN YOUR ORGANISATION (MAXIMUM 5 LINES):

PLEASE STATE YOUR INTEREST AND MOTIVATION FOR ATTENDING THIS TRAINING COURSE (MAXIMUM 5 LINES):

Please take note of the following conditions that will apply if you are selected to take part in the « Answers in the Mirror » training course :
I commit myself to participate in the whole process, including:

to prepare myself carefully for the training course
to take part in the full duration of the training course
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 « Answers in the Mirror » training course and the pictures taken during the « Answers in the Mirror » training course.
Place : Date: Signature:

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