PERSONAL INFORTMATION

Name & Surname:
Direction:
Replace with telephone number:
Replace with mobil number:
State e-mail address:
State personal website(s)  or Facebook page:
Replace with type of IM service or messaging account(s):  

Gender: Male Female
Date of Birth:
Nacionality: -- select one -- Afghan Albanian Algerian American Andorran Angolan Antiguans Argentinean Armenian Australian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Barbudans Batswana Belarusian Belgian Belizean Beninese Bhutanese Bolivian Bosnian Brazilian British Bruneian Bulgarian Burkinabe Burmese Burundian Cambodian Cameroonian Canadian Cape Verdean Central African Chadian Chilean Chinese Colombian Comoran Congolese Costa Rican Croatian Cuban Cypriot Czech Danish Djibouti Dominican Dutch East Timorese Ecuadorean Egyptian Emirian Equatorial Guinean Eritrean Estonian Ethiopian Fijian Filipino Finnish French Gabonese Gambian Georgian German Ghanaian Greek Grenadian Guatemalan Guinea-Bissauan Guinean Guyanese Haitian Herzegovinian Honduran Hungarian Icelander Indian Indonesian Iranian Iraqi Irish Israeli Italian Ivorian Jamaican Japanese Jordanian Kazakhstani Kenyan Kittian and Nevisian Kuwaiti Kyrgyz Laotian Latvian Lebanese Liberian Libyan Liechtensteiner Lithuanian Luxembourger Macedonian Malagasy Malawian Malaysian Maldivan Malian Maltese Marshallese Mauritanian Mauritian Mexican Micronesian Moldovan Monacan Mongolian Moroccan Mosotho Motswana Mozambican Namibian Nauruan Nepalese New Zealander Ni-Vanuatu Nicaraguan Nigerien North Korean Northern Irish Norwegian Omani Pakistani Palauan Panamanian Papua New Guinean Paraguayan Peruvian Polish Portuguese Qatari Romanian Russian Rwandan Saint Lucian Salvadoran Samoan San Marinese Sao Tomean Saudi Scottish Senegalese Serbian Seychellois Sierra Leonean Singaporean Slovakian Slovenian Solomon Islander Somali South African South Korean Spanish Sri Lankan Sudanese Surinamer Swazi Swedish Swiss Syrian Taiwanese Tajik Tanzanian Thai Togolese Tongan Trinidadian or Tobagonian Tunisian Turkish Tuvaluan Ugandan Ukrainian Uruguayan Uzbekistani Venezuelan Vietnamese Welsh Yemenite Zambian Zimbabwean

APPLIED FOR PARTICIPATION IN TRAINING COURSE

WORK EXPERIENCE

EDUCATION

PERSONAL SKILLS

Previous participation in training course in the frame of Erasmus+ Programme

Yes No

Agreement on Emergency Procedure

Name	Relatioship	Address	E-mail	Telephone

Medical consent form

Disabilities/ injuries

Do you have any disabilities or illnesses?

Yes No

Are there any other medical conditions we should be aware of?

Allergies

Do you have known allergies?

Yes No

Asthma

Do you suffer from asthma?

Yes No

Medications

Are you currently taking any form of medication?

Yes No

Food requirement

Are you currently taking any form of medication?

Vegetarian
Vegan
Any other food restrictions

Photograph and Publicity Release Form

I, , give the Amber Initiatives and the partner organisations, taking part in this project, the permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of the Training Course: Exploring the Potential of Social Media. I agree that the organisers (hosting and sending organisations) have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose related to the project dissemination plan. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet platforms and web sites. I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release the Amber Initiatives & partners and its National Agencies and assigns from any and all claims which arise out of or are in any way connected with such use.

I have read and understood this consent and release.

I Please, Select one give NOT give my consent to the Amber Initiatives/partners in this project to use my name and likeness to promote the project, and/or its activities.

Code of Conduct

I, confirm:

1. Full participation in the project. I understand that if I will not attend fully in the project I prove with my declaration that I may not receive any reimbursement of my travel costs.
2. I will be responsible for covering difference in cost between amount, granted according to Erasmus+ Distance band, and total cost of tickets.
3. I will prepare relevant materials in time for the activity sessions, if needed.
4. I intend to participate in all evaluation activities during the training course and after its completion.
5. I agree to participate in Follow Up activities, according to the project’s plan.
6. I will show openness and respect towards other participants and all other individuals involved in the program.
7. Show respect for, and cooperate with, participants and staff. The Code of Conduct requires participants, facilitators and staff to respect each other's dignity, values, religion and culture, irrespective of race, gender, national or ethic origin, religion, sexual orientation, age or disability.
8. Under no circumstances, commit or threaten violence toward any individual, group or the program.
9. Under no circumstances, possess, sell or consume alcohol or possess, sell or use controlled substances at the youth activity or event. * (Exception: group leaders can bring small amount of traditional alcohol for Intercultural evening).
10. Under no circumstances, attend or participate in the activity or event under the influence of alcohol.
11. To smoke tobacco, or electronic cigarettes in designated areas only.
12. Under no circumstances, bring dangerous or unauthorized materials (such as explosives, weapons or similar items) to an youth activity or event.

I Please, Select one have read have NOT read and understand the Code of Conduct. I agree to abide by the rules stated above. I understand I may be removed as a participant from the activity or program, if I fail to follow these rules, and my travel cost will be not covered.

DECLARATION

• I hereby declare that I have carefully and entirely read and understood the Project Description.
• I hereby commit myself to participate in the whole process of this project.
• I am aware that obtaining a health and a full travel insurance are my own responsibility and at my own expense. I understand that the information I have provided on my special needs does not remove my own personal responsibility for ensuring my own health.
• I hereby declare that everything stated in the present form corresponds to the truth

BANK DETAILS FOR TRAVEL REIMBURSEMENT

Name of bank
Address of bank
Name of account holder
Account number
IBAN
SWIFT code

INFORMATION FOR AN INVITATION LETTER TO SUPPORT YOUR APPLICATION FOR A VISA:

Citizenship
Country of residence
Passport number
Place of work or study (name of a company or university/college)
Occupation
Home address