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CANADA-UKRAINE
CORE-HEALTH /CORE-ECO PROGRAM 2012-2013
Application Form
Name (as in the international passport):____________________________________________________
Date & place of birth: __________________________________________________________________ ______________________________________________________________________________________
Current home address: _________________________________________________________________ ______________________________________________________________________________________
Permanent address: ____________________________________________________________________
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Telephone numbers (at home, in Ostroh, if available, and cell): ________________________________ ______________________________________________________________________________________
E-mail Address: ____________________________________________________________
Serial number of the international passport (if available): ____________________________________
College, Department, year of studying: ____________________________________________________ ______________________________________________________________________________________
Average rating for the last semester: ______________________________________________________
English skills (estimate your abilities in the 5-grade scale):
Comprehension
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Speaking
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Reading
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Writing
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Language
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Comprehension
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Speaking
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Reading
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Writing
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Are you currently involved in any social projects? ___________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________
What do you know about volunteer activities? ______________________________________________ ____________________________________________________________________________________________________________________________________________________________________________
Have you ever been involved in the similar projects?_________________________________________ ______________________________________________________________________________________
What do you expect from this program? _______________________________________________ ______________________________________________________________________________________________________________________________________________________________
Where are you going to use the experience you will get during the program?_____________________ ____________________________________________________________________________________________________________________________________________________________________________
Your interests, hobbies__________________________________________________________________
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Would you stay abroad for permanent living? Why or why not? _______________________________ ____________________________________________________________________________________________________________________________________________________________________________
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Please estimate in the 5-grade scale the abilities you are disposed to
Responsibility ___
Leadership skills ___
Communication skills ___
Ability to work with people ___
Ability to provide activities within a group ___
Ability to represent yourself (so called PR) ___
Ability to deal with conflicts ___
Creativity ___
Information about your family
Member of the Family
(Father, Mother, Siblings)
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Address
and Cell Phone Number
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Occupation
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Specify your other skills: ___________________________________________________________
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Which program would you like to participate in (the program which starts first in Ukraine or in Canada/ ECO or HEALTH )? _______________________________________________________________________________
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CORE-HEALTH/ CORE-ECO Program 2012-2013:_________________________________________
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Please, provide us with a description of a possible project that you would like to conduct during the chosen program (on a separate piece of paper, can be written in Ukrainian).
Thank you for filling the application form!
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Date Signature |
