Application Form- SMILE Group Exposure

Please complete and return this form to PRAVAH, 2nd floor, C-24 B, Kalkaji, New Delhi-110019 or email the applications to or latest by20th October, 2010.

For any queries or more information, contact Astha/Shubhi/ Sulab at 011- 26213918/ 40505743.

For more about Pravah, please visit: and

Remember don’t be scared by the length of the form! Most of it is just basic information on health and about you so that we can get to know you better. So we assure you it won’t take you too much time to fill this out!

Best of luck! 

I Personal Details

Mr./Ms.
Salutation / First Name / Middle Name / Last Name
Date Of Birth: / Age:
Gender / Male / Female / Other
Father’s Name: / Occupation:
Mother’s Name: / Occupation:

Residential Address (current):

City: / Postal Code:

Residential Address (permanent):

City: / Postal Code:
Mobile: / E-mail:
Landline (with STD code):
My contact no. in Delhi:
How did you find out about the programme:

II Educational Information

Year of passing / Name of Institution / Name of degree/ certificate/
Diploma course

IIIExtra Curricular Activities:

List any societies, clubs, groups that you have been a part of and your role:
What are your hobbies/ interests?
Have you ever been for an exposure before? If yes, then where?

IV Tell us what you think:

Just share a little about yourself… Your passion, your dreams, where you come from, where you want to go… fears, apprehensions…what you love, what you hate… your reason for being…anything that you would like to share…
Please share at least 3 strengths that you possess, and 3 things that you might want to improve on.
Why would you like to be a part of the SMILE group exposure? How do you think it ties in to your future plans? ( 150- 200 words)
Describe the image of a rural community and what according to you could be their issues of concern? (150 words)
What do you understand by active citizenship?(please give your own perspective, in not more than 150 words)

V Fees and Fellowship

The volunteer contribution for the exposure is Rs. 1000/- , towards camp costs, and a one-way sleeper class fare not exceeding Rs. 800 (the amount will be confirmed by end of October)
However, volunteer contribution can be waived off partly or fully on case to case bases.The amount paid by youwill be added to the larger pool to support volunteers who may not be able to pay for the exposure. Please share with us if you can pay this amount or if you would need support.

VI Basic Medical Information:

Do you suffer from any medical complications? Please specify and also mention the immediate measures to be taken.
Are you on any other regular medication? Please specify the name and the dosage.
Any other relevant information:

VI PLEASE READ CAREFULLY BEFORE APPLYING:

The programme will be accompanied by only the very basic facilities. While this experience will help you get out of your comfort zone and add to your learnings, we expect you to be prepared mentally and physically to tide over any challenges you may face. We also expect you to cooperate fully with the leadership team in case of any unexpected change in plans or arrangements, in keeping with the objectives of the camp and your best interests.

We are concerned about your safety and security and will take the necessary precautions from our end. However, the overall responsibility of your safety rests with you. We cannot be held liable for any untoward incidents during the course of the programme. You are expected to take complete ownership of the program and take full responsibility of all your actions. You will be expected to follow all the rules and regulations of the program that are agreed upon by the team or are communicated to you by the Team leaders from time to time.

I hereby declare that all the above information is true to the best of my knowledge.I have informed my parents/ local guardians about my plans and whereabouts. I am aware that on my return I will have to make a formal presentation and hand in a report about my exposure visit at an agreed upon time.

Name of the Volunteer:Date:

Please note that by writing/ typing your name above, along with today’s date, we are assuming that you have gone through Section VI carefully and agree to abide by all the above conditions of the programme.

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