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PARTICIPANTS APPLICATION FORM

Odyssey-Ethnic Minority Youth Leadership Training (EMYLT)


24. 07.- 02.08. 2012 Romania , Sovata
to be sent to: credo@credo.md until 10.06.2012

You apply to be: Personal Data First name: Second name: Gender: Date and place of birth: Street: City: Region: Postcode: Phone: e-mail: Personal ID number: Course details Odyssey-Ethnic Minority Youth Leadership Training (EMYLT) 24.07. 02.08. 2012, Romania, Sovata, Outward Bound Center Medical Profile Blood type:

Answer with yes or no for the questions: 1. Allergies? 2. Medication? 3. Have you been hospitalized in the past two years? 4. Cardiac problems? 5. Blood pressure problems? 6.Problems with back, shoulder, knee, ankle or other joints? 7. Other: diabetes, asthma, epilepsy 8. In case of women: pregnant? 9. Special diet? If you answered with YES any of the above items, please give details (symptoms, medication, special requests) Contact person in case of emergency: Full name: Address: Phone numbers: Relationship to you: Sending organisation Name of organisation Address Website e-mail Phone Contactpersons name and function What is your role in the organisation Learning needs survey Level of English: (bad, medium,
good, excellent)

How did you find out about this training? What is your main motivation to participate on this training?

What can you bring in to contribute to the content of the training? What personal/technical skills do you want to practice and develop? (min 30 words) What results do you expect concerning your personal development and leadership skills? (min 50 words) In which areas of your life do you want to use what you learn here? (min 50 words) Questions, remarks, anything else you want to add: Liability waiver
This program you intend to participate on is an educational program involving indoor and outdoor sports and recreational activities. The basic method is learning by experience, which means that you will have the possibility to participate in unusual activities, to experiment with different solutions and new behaviors, and to work in a group with other participants. Your experiences will be discussed in a group. The activities can include hiking, climbing, abseiling and ropes-course elements, as well as group tasks that include more or less physical effort. The programs are designed to fit the participants needs and abilities. Participants may choose to not actively participate in an activity but they still must be present for all activities. The activities are coordinated by qualified, experienced instructors, who take care of both the physical and the psychological safety of the participants. Some activities involve physical exertion, as well as known and unknown risks. I hereby accept to use all equipment and apparatus provided by the organizers. Our rules are designed to serve the safety and well-being of all participants; they need to be followed by each and every participant. The information provided by you on this form helps us design a program to fit your needs, your physical abilities and to offer help for any physical limitation you may have. All of this information is confidential. ORGANIZERS will not be held responsible for any accidents or other incidents that arise from not complying with rules and regulations.

By submitting this application I, the undersigned, confirm that I have read and understood the Information Letter and the conditions of reimbursement about the training of Odyssey- Ethnic Minority Youth Leadership Training and I know and accept the conditions of participation. Please take note of the following conditions that will apply if you are selected to take part in the training course:

I commit myself to participate in the whole process, including: to prepare myself carefully for the training course and to do all remote preparation work the team will ask for, to take part in the full duration of the training course to participate in the whole evaluation process I commit myself to organise or take part in organising in our local community event where I am able to use the gained experiences and after the program I will contribute in the execution of the final evaluation meeting (in each country separately) and the final report. This projects time frame is three months after the training. 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 I provided on my special needs does not remove my own personal responsibility for ensuring my own health. If I cancel my participation 10 days or less prior to the training course, without offering suitable replacement, a penalty fee of EUR 50 is due. In the case of 5 days or less, the penalty fee is EUR 100. Place, date: Signature:

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Instructor signature:

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