Application for New Cycles Project
10 August 2017
Section 1: Personal Information
Please fill in the blanks
1. I, Mr. / Miss / Mrs. *
Your answer
2. Nickname
Your answer
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
years
Your answer
Medical Conditions / Allergies
Your answer
Religion
Your answer
Dietary
Your answer
restrictions:
Others
Your answer
3. Current Grade
Your answer
School
Your answer
District
Your answer
Province
Your answer
4. Current Address No
Your answer
Moo
Your answer
Sub-District
Your answer
District
Your answer
Province
Your answer
Postal Code
Your answer
Home Phone
Your answer
Cellphone
Your answer
E-mail
Your answer
5. How did you learn about the project? (you may choose more than one answer)
Internet, please indicate the website
Your answer
Others
Your answer
6. Have you previously participated in similar projects?
Yes, which project? / No, because
Your answer
7. Special talents / abilities
Your answer
Section 2: Questionnaire
(You may wish to design or decorate the application form as you deem appropriate)
1. Introduce yourself in your own style
Your answer
2. Please share your experience and understanding of slum communities
Your answer
3. What are your opinions on “poverty cycle”?
Your answer
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