Program Application

Programme Applying for:  __Work camp   __M/ltv (Includes Education Exchange & Internship)

PERSONAL INFORMATION

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Last Name                                                             First Name                                                             Middle Name

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Permanent Address                                                           State/Province                                       Country                                  Zip

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Permanent Phone Number                                                  City/Area Code                                      Country Code

_______________________________________________________                                 Gender:  __Male    __Female

E-mail Address

CITIZENSHIP AND PERMANENT RESIDENCE CLASSIFICATION

Place of Birth  ______________________________________________                Date of Birth:  ____ - ____ - _______

                               City                         State/Province                        Country                                    (dd-mm-yyyy)

Country of Citizenship:  _______________________________________

Marital status (Check one):  __Single  __Married  __Divorced  __Separated  __Widow/Widower

CONTACT INFORMATION IN CASE OF EMERGENCY:

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                          Last Name                                                   First Name                                              Middle Name

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Permanent Address                                                           City                                         State/Province                        Country

Phone Number:  ___________________________________      E-mail:  _________________________________

Dates of application: From  _______________  to  _______________

How long do you want to serve?  (Weeks or Months)  ______________________________

Field of interest (Check one):  __Children  __Young People  __Disabled People  __Sex Roles  __Elderly People

                                               __Ecology/Environment  __Other _____________________

Avocations and special interests: Include hobbies, type of reading enjoyed, etc.

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Profession or Occupation: Please list special skills you possess

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Medical information: Do you have special needs that might require attention?  __Yes  __No

If Yes, what kind of attention?  ______________________________________________________________________

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Requirements for participation:

Participants are encouraged to participate for the whole period. Plan to arrive 2 days in advance so as to attend the Orientation.

Certification: I certify that I have provided complete and accurate information in this application.