Registration – H.E.L.P. Course
Geneva, 8-19 June 2015
Please send this form back before 11 April 2015to with the following documents:
-cover letter
-curriculum vitae
-2 letters of recommendation.
Personal Information
Courtesy:Click here to enter text.
Last Name:Click here to enter text.
Maiden Name:Click here to enter text.
First Name: Click here to enter text.
Date of birth: Click here to enter text.
Sex:Male ☐ Female ☐
Nationality:Click here to enter text.
Employer:Click here to enter text.
Function:Click here to enter text.
Address:Click here to enter text.
Zip Code:Click here to enter text.
City:Click here to enter text.
Country:Click here to enter text.
Phone:Click here to enter text.
Mobile phone: Click here to enter text.
Fax:Click here to enter text.
E-mail address:
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Sponsor
Who is paying for your training? Self (no sponsor) ☐ICRC ☐Other☐
For ICRC sponsored-participants:
Cost Center Click here to enter text.Objective Code Click here to enter text.
Delegation Click here to enter text.Contact Person in the DelegationClick here to enter text.
For other sponsored participants:
Name of sponsor: Click here to enter text.
Postal address (compulsory for invoice): Click here to enter text.
Invoice to be sent by post ☐e-mail ☐
Payment mode: Credit card☐Bank transfer☐
Background experience and motivation
Academic Background
Please list your main health and medical degrees and training course with dates
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Professional Experiences
Describe previous job experiences relevant to the course, start with most recent
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Field Experience
Describe one field experience which shows best the type of activities you have been involved in
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Reasons for attending the course
Explain what you expect from the course in relation to your future work
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Visa Information
Do you need a visa? Yes☐No ☐
If yes, please indicate your passport details or send a copy of your passport:
Nationality: Click here to enter text.
Passport n°:Click here to enter text.
Place of birth: Click here to enter text.
Place of issue: Click here to enter text.
Date of issue: Click here to enter text.
Expiration date:Click here to enter text.
Travel and accommodation
Flight information:
This information is essential if you are accommodated in the hotel booked by the ICRC. It can also be provided later:
Arrival dateClick here to enter text.
Arrival time Click here to enter text.
Flight number Click here to enter text.
Departure date Click here to enter text.
Departure time Click here to enter text.
Flight number Click here to enter text.
Hotel room
The ICRC has pre-booked rooms for participants at Lake Geneva Hotel
It is located near Ecogia (Versoix), the ICRC training center where the H.E.L.P. course will take place.
The rate is CHF 153.30 including breakfast.
Should you wish to look for other accommodation, please note that you will have to reach the training center by your own means every morning.
Would you like to book a room at Hotel Lake Geneva? Yes☐No ☐
Arrival date:Click here to enter text.Departure date:Click here to enter text.
Total number of nights:Click here to enter text.
Food preferences
Please indicate if you have any dietary restriction or preference
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Comments
Any comment that you would like to share with the organizers?
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