“SAVE Toolkit”Training Application Form:

Emthonjeni Pastoral Centre, Kumalo, Bulawayo. Catholic Archdiocese of Bulawayo, Bulawayo,Zimbabwe

Date: 11 - 14 November 2013

Make sure that you complete the entire application form. If the form is incomplete, we cannot consider your application.

Numbers are limited.

Trained Churches Channels of Hope facilitators who have completed their application forms by 18 October will receive preference.

  • Send your completed application formas soon as possible by e-mail: ORby fax+2721- 8730028.
  • Closing date for applications:23rd October 2013.
  • We will inform you no later than 25th October 2013 if your application was successful.
  • The training is fully sponsored. This includes training material, all meals and accommodation, but excludes traveling cost.
  • All participants are responsible for their own travel arrangements and costs.
  • If there is enough interest, a shuttle will be provided from ACET offices, Bulawayo at a time determined by CABSA.
  • Please note that we will attempt to provide for health or religious diet restrictions, but cannot do this at the last moment. If not indicated on this form, your diet restrictions cannot be catered for.
  • Important requirements for all participators:
  • This training and the resource material provided is in English. It is therefore important that participants arecomfortable reading and writing in English
  • Participants are expected to attend for the full scheduled time. Evenings may also be used for programme events. Please do not arrange other meetings and social events during this time.
  • Training starts at 14h00 on the 11th of November (registration starts at 13h00) and ends at 13h00 on the 14th November 2013.

Venue:

Emthonjeni Pastoral Centre, Kumalo

PO Box 127 AC

Ascot, Bulawayo

Kumalo

Ludlow Hewitt Road

1 / IDENTIFICATION DETAILS
1.1 / Surname: / 1.2 / First Name:
1.3 / Postal Address: / 1.4 / Tel. (Home) :
1.5 / Tel: (Work):
1.6 / Cell Phone:
1.7 / Fax:
Province: / 1.8 / E-mail:
Country: / 1.9 / Profession/Job:
1.10 / ID Number:
1.11 / Sex:  Male /  Female
1.12 / Title:  Mrs. Ms. Mr. Pastor/Priest/Reverend Other (Please specify) ……….
1.13 / Do you have any dietary restrictions?
Yes
No
1.14 / If yes, please give guidelines:
1.15 / Disability status:
 Physical Sight Hearing Other (Please specify) …………………………………..
1.16 / Will you be interested in transport:
- from ACET offices, Bulawayo on 11/11/2013
Yes
No
-To ACET offices, Bulawayo on 14/11/2013
Yes
No
2 / CHURCH AFFILIATION AND INVOLVEMENT
2.1 / To which denomination do you belong?
2.3 / Describe your involvement in your local church/congregation: (Mark with “x”)
 Pastor/Minister/Priest
 Leader of ______
 Other involvement (explain)
2.4 / (If applicable) Which organisation do you represent?
3 / INVOLVEMENT IN THE HIV FIELD
3.1 / Have you completed the “Churches, Channels of Hope” Facilitators Training?
Yes
No
3.2 / If “Yes”, when and with which organisation?
3.3 / Have you attended any other workshops and/or training on HIV and AIDS?
Yes
No
3.2 / If “yes”, give more information about at least two:
Type of workshop / Duration
(1)
(2)
3.3 / Do you personally have any contact with people living with HIV? / Yes / No

I, the undersigned ………………………………………………………………… (full names)

Commit to attending the SAVE Toolkit Training from on 11-14 November 2013 if I am selected for this course. I hereby declare that I am attending this training at my own risk. The Administration, officials or employees of CABSA, INERELA+ and EMTHONJENI PASTORAL CENTRE, CATHOLIC ARCHDIOCESE OF BULAWAYOshall not be held responsible for any ill effects or losses of health or property sustained or arising out of my attending the said training at the said venue.

I hereby further, on behalf of myself, my executors, heirs and assigns indemnify and absolve the Governing Body, organisations, their officials and employees from any claim of whatever nature, arising from such attendance, activities and travelling.

Signature: ______Date: ______