APPENDIX OF APPLICATION FORM
FOR
Training of Managerial Personnel of Independent Living Centers for People with Disabilities

Please submit all pertinent documents and your answers to this questionnaire in typewritten form together with your Fellowship Application Form. **This appendix is available at http://www.apcdproject.org/trainings/il06/

TITLE Mr.
Ms.
Mrs.
Dr. 		NAME (capital letter)  
GENDER MALE
FEMALE 		FAMILY NAME GIVEN NAME MIDDLE NAME
BIRTH DATE (Day/Month/Year):

PASSPORT NUMBER:

PASSPORT EXPIRY DATE (Day/Month/Year):

HOME ADDRESS:

 

TELEPHONE NUMBER (Country Code/Area Code/Number):

FAX NUMBER (Country Code/Area Code/Number):

NAME OF THE ORGANIZATION:

 

ADDRESS:

 

TELEPHONE NUMBER (Country Code/Area Code/Number):

FAX NUMBER (Country Code/Area Code/Number):

 

E-MAIL ADDRESS:

Page break

DISABILITIES
(IF ANY)

YES.
NO.

TYPE OF DISABILITIES Physical Disability
Hearing Disability
Visual Disability
Intellectual Disability
Mental Disability
Other
  USAGE OF ASSISTIVE DEVICES: YES NO
DETAIL OF YOUR ASSISTIVE DEVICES:
  1. Power/electronic wheelchair ( Wet battery Dry battery)
  2. Wheelchair
  3. Crutch (es)
  4. White cane
  5. Other (                                )
NECESSITY OF A PERSONAL ASSISTANT FOR THE TRAINING:
  1. YES => (Details)
  2. NO
NECESSITY OF A SIGN INTERPRETER FOR THE TRAINING:
  1. YES => (Details)
  2. NO
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, Japan International Cooperation Agency (JICA) 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 in 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, Japan International Cooperation Agency (JICA) and/or the Asia-Pacific Development Center on Disability.

 

 

SIGNATURE OF NOMINEE

PRINTED NAME OF NOMINEE (________________________________)

DATE:

Page break

QUESTIONNAIRE

*Please submit your answers to the following questions as a part of the "Appendix of the Application Form."

Q.1 What does "IL (Independent Living)" mean to you? Also, what does "Peer-counseling" mean to you?

Q.2 Is there any plan to initiate/strengthen an Independent Living Center (ILC) in your country? If so, please explain the plan briefly (When/Where/Who/What).
Also, what role are you planning to take in the plan?

Q.3 Do you have any experience related to "Peer-counseling", please share (e.g., How Long/Where/What to do).

Q.4 What kind of persons can be "good peer-counselors"? Please state 4 desired characteristics of "good peer-counselors" from your point of view.

Download the Appendix of Application Form and Questionnaire in PDF format (26.7 KB)

Back

[ Top go to top ]