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APPENDIX OF APPLICATION FORM
for
Workshop for Strengthening Community Based Rehabilitation (CBR) Movement

Please submit all pertinent documents and your answers to this questionnaire in typewritten form (page 7 - 10) together with your Fellowship Application Form.

Download Application Form for CBR in PDF format (116 KB)


TITLE Mr.
Ms.
GENDER MALE
FEMALE
NAME (capital letter)    
 
FAMILY NAME GIVEN NAME MIDDLE NAME
HOME ADDRESS:





TELEPHONE NUMBER (Country Code/Area Code/Number):
FAX NUMBER (Country Code/Area Code/Number):
EMAIL ADDRESS:
NAME OF THE ORGANIZATION:



ADDRESS:



TELEPHONE NUMBER (Country Code/Area Code/Number):
FAX NUMBER (Country Code/Area Code/Number):
EMAIL ADDRESS:
DISABILITIES (IF ANY)
 
YES
NO
TYPE OF DISABILITIES: Physical Disability Hearing Disability
Visual Disability Intellectual Disability
Mental Disability Other (                  )
USAGE OF ASSISTIVE DIVICES: YES NO
DETAILS OF YOUR ASSISTIVE DEVICES:
  Power/electronic wheelchair ( Wet battery Dry battery)
  Wheelchair
  Crutch
  White cane
  Other ( )
DIETARY REQUIREMENT (IF ANY)

I hereby certify that all the provided information is correct, accurate and complete to the best of my knowledge.

In the event that I suffer injury, illness or death during the course of my participation in the program/course, I shall hold the Royal Thai Government, the Government of Japan and/or the Asia-Pacific Development Center on disability harmless and without any liability whatsoever for compensation towards myself, my legal representatives and/or my heirs. Should I cause any person loss of property, injury, illness or death during the course of my participation the program/course, I shall be fully responsible and liable for the said person without reference whatsoever to the Royal Thai Government, the Government of Japan and/or the Asia-Pacific Development Center on Disability.




SIGNATURE OF NOMINEE ........................

PRINTED NAME OF NOMINEE (                         )

DATE:
Print Appendix of Application Form for Workshop for Strengthening Community Based Rehabilitation (CBR) Movement
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Download Questionnaire for CBR in PDF format (84 KB)

Questionnaire

Q1     What is CBR? (briefly explain it from your points of view)
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Q2.     What do you think about your implementation of CBR (strength/weakness)?
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Q3.     How do yo plan to develop CBR in your country/community?
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Q4.     What are successful factors of CBR according to your ideas?
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Print Questionnaire

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