Other Relevant Experience

21. Briefly describe any relevant volunteer experience, community involvement, etc.

Part 4: Health & Other Information

Health & Medical Information

22. Do you have any physical, emotional, or psychological conditions that we should be aware of? Yes No

If yes, please describe:

23. Do you have any dietary restrictions and/or allergies? Yes No

If yes, please describe:

24. Do you have health and/or medical insurance? Yes No

If yes, please indicate the following:

Type of coverage:

Provider:

Policy Number:

Other Information

25. How did you hear about this fellowship?

26. Do you have access to a computer and the internet? Yes No

If yes, where? Home Work Other:

Part 5: References

Reference Contact Information

Please list your two references below so that we may contact them.

27. First Reference Contact Information:

Name:

Title:

Organization:

Address:

Country:

Postal Code:

Phone number:

Fax number:

Email address:

28. Second Reference Contact Information:

Name:

Title:

Organization:

Address:

Country:

Postal Code:

Phone number:

Fax number:

Email address:

Part 6: Your Organization

Organization Purpose

29. In one sentence, please describe the overall purpose or goal of your organization:

Organization Size

30. Number of full-time employees:

31. Number of part-time employees:

32: Number of volunteers:

33: Number of employees directly under your supervision:

34. Name and title of your direct supervisor:

Organization Budget

35. Overall budget of organization:

36. Where does your funding come from?

37. Does your organization have an endowment?

Organization Official Registration

38. Date officially formed:

39. Government or administrative body registered with:

40. Location of headquarters / main office:

Date: 2016-01-05; view: 741