Photo 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: ____________________________________________________________________ ______________________________________________________________________________________ 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 | Speaking | Reading | Writing |
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| ^ Language | Comprehension | Speaking | Reading | 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__________________________________________________________________ ______________________________________________________________________________________ Would you stay abroad for permanent living? Why or why not? _______________________________ ____________________________________________________________________________________________________________________________________________________________________________ ^ -
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) | Address and Cell Phone Number | Occupation |
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| ^ ____________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Specify your other skills: ___________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
Which program would you like to participate in (the program which starts first in Ukraine or in Canada/ ECO or HEALTH )? _______________________________________________________________________________ ^ CORE-HEALTH/ CORE-ECO Program 2012-2013:_________________________________________ _______________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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! ______________________ ______________________ Date Signature |