Training Course: Let Me Lead You(Th) to Success

Training course: Let me lead you(th) to success

Gozo (Malta) – 26th to 31st October 2015

REGISTRATION FORM

Please fill in this form as accurately as possible by typing and return it to us before the 5th of September.

1. Data of the participant

Information contained on this section will be shared with the donors. Only your name and country might be made publicly available while all the other data should remain confidential. You might be contacted directly by the donors. If you do not agree, please tick the box bellow:

I do not agree to be contacted by the donors

Full name: / Sex:
male female
Date of birth: / Place of birth:
Address:
Street:
Number:
City:
ZIP/postal code: / ID Number:
Phone Contact:
National prefix: + Number:
Country:
E-mail:

2. Journey details

Please fill in if known

Arrival day / Arrival time / Arrival place / Flight/Train Number
Departure day / Departure time / Departure place / Flight/Train Number

3. Emergency Contacts

Please give at least one contact person who can always be contacted in case of emergency during the dates of the activity (this information is strictly confidential)

Name: / First Name:
Relation degree with the participant:
(e.g. mother) / Phone Contact:
Name: / First Name:
Relation degree with the participant: / Phone Contact:

4. Medical information (This information is strictly confidential and it will be shared with third persons only in case of medical need)

Click twice on the squares you want to select and choose “activate”

Are there diseases to be mentioned? (e.g. asthma, diabetes, dermatitis, epilepsy, affections of the heart, others,….)

Yes Which one(s):

Does the participant have to take medication during the seminar?

Yes What kind?:

Is the participant sensitive or allergic to…:

Medicines NoYes Which one(s)?:

Substances (peanuts, gluten, lactose,…) No Yes

Which ones?:

Medication?/Treatment?:

FoodNoYes Which ones?:

Medication?/Treatment?:

5. Dietary regimes:

Do you have any specific dietary requirements (eg. Vegetarian, vegan..)

NoYes Which ones?

Any other information or remarks

Expectations

What do you expect to get from attending this seminar, both as an individual and for taking back to your organisation?

Training course: Let me lead you(th) to success

Gozo (Malta) – 26th to 31st October 2015

PARENTAL AUTHORISATION

(OBLIGATORY FOR MINORS)

When the participant is a minor (under 18 years old), the parental authorisation to take part in the Seminar is required. Please fill in the name of your child and sign this paper if you agree with it.

As parent/legal guardian, I agree with the participation of (full name)…...... …………………………….... in the Training Course of MIJARC Europe from 26th July to 31st of October 2015 (travel days included), in Gozo (Malta), undertaking the responsibility for his/her acts and behaviour during this period.

I authorize the persons in charge of the activity to take decisions (treatment, hospitalization, surgery, etc) which have to be taken according to the health of the minor in case of need.

Name:

Place: ______

Date: ____/____/2015 Signature

Please, return a scanned version of this completed form dully signed to

as soon as possible and bring the paper version with you for the activity.

Rue Joseph Coosemans, 53 * 1030 Brussels * Belgium

* GSM : 0032 485368474