2008 Global Challenges

for Young Persons with with Disabilities

Application Form

Last name			First name		Photo
Title	Mr./Mrs./Miss/Ms		Date of birth
Home address
Phone number			Cell phone
Email address			Nationality
Emergency contact	Name: Relationship: Contact Number:
Type and Level of Impairment	Please give us a detailed description of your difficulties in all areas that your impairment affects.(ex. visual impairment—How far and how much details you can see)
Do you require assistance?	Yes (   ) No (    ) *If yes, please describe in details
Do you require aids?	Yes (    ) No (    ) *If yes, please tell us what it is.
Daily and/or emergency medical care
Work *Relevant qualification & certification to be submitted
Period (From the recent year)		Name of company Address and Tel.	Post		Description of work
Education *Relevant qualification & certification to be submitted
Period (From the latest year)		Name of Uni. / Schools (Incl. Address)		Major	Achievement & Special activities
Proficiency of English				First Language
Verbal: Upper/ Medium / Lower Written: Upper/ Medium / Lower * You can refer to internationally certified English Tests
				Other languages
Skills and/or interests
* Please describe your personal talents, interests and special skills (i.e. Filming, sign language interpretation etc.
Participant Agreement
1. All the participants should make commitment to take a full and active part in each aspect of the program, from group orientation to evaluation. 2. The success of the international study program depends on friendly and respectful interaction with each other and with all members of the communities where the program will be studied. All participants should bear in mind that they will be working in a multi-cultural team (with people from Cambodia, Korea, the Philippines, and Vietnam) and that full understanding of each others’ cultural differences may pose challenges at times during the short duration of program involvement. 3. All the participant should abide by the laws of Republic of Korea. 4. Any problems and difficulties that the participants encounter should be reported to the team leader for advice. The team leader can further discuss these with the representatives in each country. Once decisions are made by the team leader, the participants should accept it. 5. For health and safety reasons, all individual activities must obtain permission from the team leader. 6. Criminal Reference/Record Check is required I hereby declare that I agree to adhere to all of the above during the program and, I authorize representative organization to check references and validate this information. Name: Signature: