Eyexcel: Expanding Global Eye Care Workforce Through Excellence in Training

Eyexcel: Expanding Global Eye Care Workforce through Excellence in Training

July 11 – 14, 2017Application Form

1. Organization Details:

Organization Name: Click here to enter text.

Type of Organization: Government ☐/ Private ☐ / Voluntary Organization ☐ / Other ☐

Organization Address for Communication:

Street:Click here to enter text.

City: Click here to enter text.

State:Click here to enter text.

Country:Click here to enter text.

Postal Code:Click here to enter text.

Phone No:Click here to enter text.

Fax No:Click here to enter text.

E – Mail: Click here to enter text.

Website: Click here to enter text.

2. Your Training Project:

(Your team will be working on ONE specific Training Project during the Eyexcel course as an example. Please give a brief description of this project here. Even if you offer several training programmes – mention ONLY ONE here)

Type of Project:

☐ Improving an already existing training programme (Fill out Box A & B)

☐ Expanding a training programme (Fill out Box A & B)

☐ Initiating a new training programme (Fill out Box B)

Box A: Details regarding existing training programme
i) Name of the Training Programme:
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ii) Length of training programme:
6 months ☐1 year ☐2 year ☐ Other (specify) Click here to enter text.
iii) What is the number of students you take in each batch?
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iv) What year did you begin your training programme?
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v) What curriculum and instructional materials do you use in your programme?
(PLEASE ask you team to bring samples of current materials with them)
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vi) What are your key challenges in running this programme?
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Box B:
Briefly describe the training programme:
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What is the need for this training programme?
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What are the major goal/objectives of your training programme?
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What is the plan for implementation of your training programme?
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What work has already been done on your training programme?
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List the other training programmes you offer at your institution:
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3. Participating Team:

List the names and positions of the persons on your Eyexcel Team:

Particulars / Team Member 1 / Team Member 2 / Team Member 3
Title / Mr ☐ Ms ☐ Dr ☐ / Mr ☐ Ms ☐ Dr ☐ / Mr ☐ Ms ☐ Dr ☐
Participant Name / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Gender / Male ☐ / Female ☐ / Male ☐ / Female ☐ / Male ☐ / Female ☐
Nationality / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Passport No / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Designation / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Email Id / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Mobile Number / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Skype Id / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Who in your team will be our contact person (Please tick one): / ☐ / ☐ / ☐ /
Who do you report to?
Name of reporting authority / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Designation / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Email Id / Click here to enter text. / Click here to enter text. / Click here to enter text. /
Mobile Number / Click here to enter text. / Click here to enter text. / Click here to enter text. /

Is this team already working together?

Yes ☐No ☐

What are three things you expect your team to learn/be able to do after attending Eyexcel?

1.

2.

3.

4. Payment of Fee:

a) Self Financing: ☐

b) Sponsored: ☐

Mode of Payment: Cash ☐DD☐Wire Transfer ☐

If sponsored, please provide the following details.

Name of the Sponsoring Organization: Click here to enter text.

Name of the contact Person: Click here to enter text.

Designation: Click here to enter text.

Street:Click here to enter text.

City: Click here to enter text.State:Click here to enter text.

Country:Click here to enter text.Postal Code:Click here to enter text.

Phone No:Click here to enter text.Fax No:Click here to enter text.

E – Mail: Click here to enter text.Website: Click here to enter text.

Declaration: We declare that the information provided in this application and the documentation supporting it is correct and complete.

Date: Click here to enter a date.