Roots finding Poverty fightingKalamata, 23-29 March 2014Participants formContact details

First Name:PHOTO

Surname:

Address:

City: Postal code

Region: Country:

Telephone: (With prefix)

Mobile: (With prefix)

E-mail:

Personal data

Date of birth:

Nationality: Gender: Male Female Other

Do you have any allergies? YES NOIf yes, specify:

Do you have any particular dietary needs? (vegetarian, vegan, no pork, Other) YES NOIf yes, specify:

Have you already been abroad? YES NOIf yes, WHERE?For how long? < 3 MONTHS < 6 MONTHS < 1 YEAR > 1 YEAR

Emergency contact

Name and Surname:Gender: Male Female Other

Full Address:

telephone: mobile:

Language ability

LanguageBasicIntermediateGoodFluentMother tongueBasic

English

Organisation information

Which organisation are you representing? Please describe the main activities of your organisation.

raplection, croatia

What is your role in the organisation?

Volunteer & youth worker

Do you have personal or professional experience in natural and/or traditional practices? If yes please describe.

Why do you want to participate in this seminar?

How do you think you can contribute in this project?

If a gennie could grant you three wishes what would they be?

Is there something you want to add?

Please fill in and send this form by the 11st of December 2014.

THANK YOU FOR YOUR TIMEand we cannot wait meeting you soon!