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)
☐ Lithuanian
☐ 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.   Mobile phone:       

14.   Email:      

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

INFORMATION ON THE ORGANISATION/INSTITUTION/GROUP

 

16.   Name of the organisation/institution/group that supports your participation at the training workshop:      

17.   Postal address      

18.   Telephone:      

19.   Fax:      

20.   Email:      

21.   Internet address:      

22.   Please describe briefly the aims of your organisation/institution/group, target groups and main activities related to the topic of the training:      

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

☐leader

☐ 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 (human rights, human rights education, antigypsyism, remembrance):       

MOTIVATIONS AND INTEREST IN THE TRAINING SEMINAR

26.   What are your expectations about the training workshop?

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

28.   What activities do you plan to implement after the training workshop?       

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

☐ Yes.
☐ No.