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Breakout Boxes Application Form
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* Indicates required question
Name
*
Your answer
Surname
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Your answer
E-mail address
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Your answer
Country of residence
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Your answer
Place of residence
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Your answer
Nationality
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Your answer
Gender
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Female
Male
Other:
Phone number (with international prefix)
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Your answer
Date of birth
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MM
/
DD
/
YYYY
Please, describe your connection to working with young people (both professional and voluntary).
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Your answer
Please, describe your motivation to participate in this training.
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Your answer
Special dietary infomation
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Your answer
Other relevant health related or special needs (allergies, mobility restrictions, medical needs)
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Your answer
I hereby declare that I have entirely read and understood the project description, infopack and reimbursement rules.
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Yes
No
I hereby commit myself to participate in the whole process of this training, meaning in the 100% of the work programme. Failure to do so might result in non-return of my travel expenses or even withdrawal from the project activity.
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Yes
No
I am aware that I am responsible for carrying out preparatory tasks asked by the organizers as well as dissemination activities after the training.
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Yes
No
I am aware that obtaining a health and a full travel insurance are my own responsibility and at my own expense. I understand that the information I have provided on my special needs does not remove my own personal responsibility for ensuring my own health.
*
Yes
No
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