Hrvatska kola Outward Bound

Outward Bound Croatia

1. COURSE PARTICULARS
Name

Youth exchange Hear our voice,

gender equality is the right choice

Date and place

17.10. - 25.10.2015. Samobor, Croatia

2. PARTICIPANT'S PARTICULARS

First, last name

Se
x

Date of birth, Age

Passport number
Address
City, postal code
Country
Phone number
E-mail
Facebook name (to add you in
Facebook group of the project)
Occupation
T-shirt size (XS, S, M, L, XL,
XXL)

3. CONTACT PERSON'S PARTICULARS

(In case of emergency)
First, last name
Address
Phone number
Relation to participant

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Hrvatska kola Outward Bound

Outward Bound Croatia

4. MOTIVATION FOR THE EXCHANGE

Please answer each question, give true answers, specific to you.
Consider, that based on your answers we can develop the program in a
way that serves your needs.
General answers do not support.
What makes you interested in
this exchange?(min. 50
words)
What personal skills do you
want to practice and develop?
(min. 50 words)
What results do you expect
concerning your personal
development? (min. 50
words)
What do you want to learn
concerning the themes of the
exchange? (min. 20 50
words)
In which areas of your life do
you want to use what you
learn here? (min. 50 words)
Questions, remarks, anything
else you want to add:

Special diets and needs (vegetarian, religious diets, physical

limitations):
_________________________________________________________

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Hrvatska kola Outward Bound

Outward Bound Croatia

5. PARTICIPANT'S MEDICAL PROFILE

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Hrvatska kola Outward Bound

Outward Bound Croatia
Do you have any of the following
conditions?
Yes

No

Please answer YES Or NO.

If Yes please explain:

Explanatio
n

-Heart problems
-High blood pressure
-Asthma
-Other respiratory/lung problems?
-Difficulty breathing when excercising
-Chronic Cough
-Headaches
-Epilepsy
-Fainting

Do you have any of the following

conditions?
Please answer YES Or NO.
If YES please explain:
Yes

No

Explanatio
n

-Diabetes
ALLERGIES to medicines/food/insects/?
If YES,
-Please describe your reaction.
-Have you had Anaphylaxis?
-Have you been hospitalized?
Have you been Hospitalized within the
last 2 years?

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Hrvatska kola Outward Bound

Outward Bound Croatia

Do you have bone or joint problems?

Do you have any skin diseases or
sensitivities?
Please list any Medications and dosages
if you use them
Have you recieved tuberculosis and/or
typhoid fever vaccinations?
Have you received immunizations and
Tetanus shot?
Please list date.
Do you have special dietary requirements
or allergies to foods?
Do you have other health concerns?

..
Participants name
Signature

SEND APPLICATION TO:

Date

erasmus.yp@gmail.com till 9.10.2015. at

12:00.

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