41-1, Jalan Sulaiman 3, Tmn Putra Sulaiman, Ampang 68000, Selangor
Email:
Registration #: 07– / Photo
Name / (As it appears on your passport)
Present address / City: / State/Prov:
Zip: / Country:
Tel:(h) (W) (Fax)
e-mail / Sex / □ Male □ Female
Date of Birth / Citizenship
Passport No. / Place of issue
Date of issue / Expiration date
Emergency
Contact / Name: Relationship:
Tel: e-mail:
Address:
Health / Do you have any medical concerns? □ Yes □ No
If yes please describe: / Blood type
( )
Language abilities / □ English (1 / 2 / 3 ) □ Indonesian (1 / 2 / 3 ) □ Japanese (1 / 2 / 3 )
□ Arabic (1 / 2 / 3 ) □ etc.( )
1- Limited 2- Fairly Well 3- Fluently
Occupation
/ Major / Certificates of qualification
Location / Aceh Indonesia / Timor Leste / Afghanistan / PakistanKashmir
1st choice: / 2nd choice:
How did you get to know about this program? / □ friend □ school □ church □ poster □ others ______
I wish to join the 2007 Peace Camp.
Forms: 1. Peace camp application
2. Self-introduction. Personal essay
3. Letter of commitment (to be signed during the training period)
Date Month Year
Applicant : (sign here)
Self Introduction/Personal Essay
▶Self Introduction
▶Personal Essay: Why do you wish to join this camp?
Pledge about personal safety charge
I (Name) pledge to perform the duties and activities of
‘The Frontiers’ for peace and reconciliation from Year Month Day
until Year Month Day as and below.
I know that the foreign areas where I will perform are endangered by wars and conflicts and that there can be violence which can harm me. The reason for my participation in activities by the organization after all lies in the belief that we have the responsibility to make the world peaceful.
I am aware of the fact that I might get illegally arrested, imprisoned, inflicted with physical and psychological pain, become handicapped or even die while working with ‘The Frontiers’. I also know that conflict areas where the organization works do not have appropriate health and hygiene facilities so that drinking water, food and lodging facilities are poor.
I am resolved that I can inflict injury, sickness, obstacle, loss, imprisonment and even death by participating in activities of ‘The Frontiers’ and accept to take the whole responsibility of such dangerous incidents.
I accept that the security of ‘The Frontiers’ staff and volunteers in the front line of their activities can not be guaranteed and I will not demand the responsibility in case of unintended accidents. In case of my death during activities, I ask ‘The Frontiers’ to confer the bereaved family and deal with my corpse according to the will I left.
I am an at least 18 years old adult and thoroughly understand and accept the content of this pledge. I make clear that I will after all participate in this service not because of foreign enforcement or repression but because of my belief and conscience to participate with those suffering in conflict areas according to a voluntary resolution in front of several witnesses.
Year Month Day
Person who pledges (signature)
Witness No.1 (signature)
Witness No. 2 (signature)