INFORMATION ON THE APPLICANT

1.       Surname:                

2.       Name:         

3.       Which gender do you identify with?

☐ Man
☐ Women
☐ Other

4.       Age:      

5.       Nationality:      

6.       Country of residence:      

7.       Working languages (please specify all your working languages)
☐ Italian
☐ Other:      

CONTACTS - Please note all correspondence will be sent to this address – please ensure it is complete.

8.       Postal Address: COUNTRY:      

9.       Postal Address: CITY:      

10.   Postal Address: POSTAL CODE:      

11.   Postal Address: STREET AND NUMBER:      

12.   Telephone:      

13.   Fax:      

14.   Mobile phone:       

15.   Email:      

16.   Do you have any special needs or requirements (e.g. dietary, disability, etc.)?        

INFORMATION ON THE ORGANISATION/INSTITUTION/GROUP

 

17.   Name of the organisation/institution/group that supports your participation at event:      

18.   Postal address      

19.   Telephone:      

20.   Fax:      

21.   Email:      

22.   Internet address:      

23.   Your organisation/institution/group is…:

☐ a Roma international youth organisation or network

☐ an international youth organisation or network 
☐ a local or national Roma youth organisation
☐ a local or regional youth organisation

☐ a governmental organisation
☐ a Human Rights organisation

☐ a minority or minority rights organisation
☐ a national youth council
☐ a formal education institution
☐ an informal local group
☐ other (please specify):      

24.   What is your own role/responsibility within your organisation/institution/group?

☐ volunteer

☐ employee

☐ active member

☐ board member
☐ civil servant
☐ youth worker

☐ trainer

☐ project officer

☐ manager of projects

☐ other (please specify):      

25.   Please describe your most relevant experiences in relation to topic of the training workshop (antigypsyism, discrimination and hate speech):       

MOTIVATIONS AND INTEREST IN THE TRAINING WORKSHOP

26.   Why would you like to attend the training workshop?      

27.   What do you want to learn from this activity?

Follow-up and Implementation

28.   How do you plan to follow-up the training workshop in relation to combating antigypsyism and hate speech against Roma young people? How will your organisation/institution/group support you in this process?       

29.   I am available to attend the full duration of the training workshop

☐ Yes.
☐ No.