LEAP AFRICA'S SOCIAL INNOVATORS PROGRAMME- 2015/2016 APPLICATION
APPLICATION DEADLINE AUGUST 31, 2015!
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Name (SURNAME, First Name) *
Gender (Male, Female) *
Date of Birth *
MM
/
DD
/
YYYY
Parmanent Residential Address *
City *
State of Origin *
Phone Number *
Email Address *
Mailing Address *
State of Primary Residence *
Skype ID
Facebook page
Twitter
Blog
Website
Highest Level of Education ( E.g. B.Sc, M.Sc, PHD) *
Name of Project/Initiative/Organization *
Location of Project/Initiative/Organization *
Has your project demonstrated impact for at least one year as at the time of this application? If yes, briefly give details *
Are you the founder or co-founder of this Project/Initiative/Organization? *
About Your Initiative *
How did you find out about the Social Innovators Programme? Tick all options applicable *
Required
Please select the field in which your project/organization primarily fits? Please pick one *
Required
Which of the following best describe your project/initiative/organization? *
Required
If your project resides within an organization, please provide the name of the organization
Is your project formally registered as an organization? If yes, please provide details of registration
Which of the Millennium Development Goals (MDGs) are you addressing? Please tick *
Required
Which of the below issue areas does your project/organization impact? Please choose all that apply *
Required
Which of the below issue areas does your project/organWhich of the below methods / approaches are you using to achieve change in your area of interest? Please choose all that apply.ization impact? Please choose all that apply *
Required
Describe your idea/initiative. Maximum 100 words. *
How many beneficiaries did your project/initiative reach in the year 2014? Please specify numbers of direct and indirect beneficiaries *
TELL US ABOUT YOURSELF. *
What are your skills, capabilities and personality traits? *
What or Who inspired you to start this project/initiative? (Maximum 150 words) *
What do you want to learn? Please select from this list the three (3) most relevant types of learning support that would help you achieve your goals and objectives *
Required
What is unique about your idea/initiative/organization? Maximum 100 words *
Do you run the initiative/project/organization full-time? Do you also have volunteers? If yes how many? Maximum 100 words *
Which of the following funding sources apply to your organization? *
Required
In 2014, what were your primary sources of funding? (Please check all that apply) *
Required
If you have formed partnerships to implement your project, please select sectors with which you have formed partnerships. (Please check all that apply) *
Required
How do you sustain your project/initiative/idea? Maximum 100 words *
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