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My Friendship with the Planet
Erasmus+: Youth, Key Action 1: Youth Exchange
Venue: Łódź, Poland
Dates: 11—21 July 2022
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APPLICANT INFORMATION
Name
*
Your answer
Surname
*
Your answer
Gender
*
Choose
Female
Male
Date of birth
*
MM
/
DD
/
YYYY
Age at the time of the project:
*
Your answer
Citizenship
*
Choose
Czech
Slovak (and I live in Slovakia)
Slovak (and I live in the Czech Republic)
Other and I do have a valid residency permit in the Czech Republic
Other and I do NOT have a valid residency permit in the Czech Republic
I am a Ukrainian citizen and I have been granted temporary protection in the Czech Republic
If you answered "other" in the above 'Citizenship' section, please state your citizenship/nationality:
Your answer
Full address
*
Your answer
Current country of residence
*
Your answer
Region:
*
Choose
Hl. město Praha
Středočeský
Jihočeský
Plzeňský
Karlovarský
Ústecký
Liberecký
Královéhradecký
Pardubický
Kraj Vysočina
Jihomoravský
Olomoucký
Moravskoslezký
Zlínský
Not applicable, I do not live in the Czech Republic
Email address
*
Your answer
Mobile phone number
*
Your answer
Link to your social media profile
*
Your answer
Passport expiry date (if you do not own a passport, please do NOT apply for this project)
*
MM
/
DD
/
YYYY
Do you have any special needs or requirements that the host organization should know about? (E.g.mobility, medical needs, allergies, dietary restrictions such as vegan)
*
Your answer
Please let us know about your Covid-19 vaccination status:
*
I will be fully vaccinated with a two-dose vaccine. At least 14 days will have passed since my 2nd vaccination and the start of this project
I will be fully vaccinated with a single-dose vaccine (Johnson&Johnson). At least 21 days will have passed since my vaccine and the start of this project
I will only have received the first vaccine (of a two-dose vaccine)
I do not intend to be vaccinated
I have recovered from Covid-19 disease (and I have a certificate proving so). It will have been fewer than 180 days since my first positive Covid-19 PCR test and the end of this project.
Other:
Please tell us if you find yourself in any of the following categories:
Please tell us if you find yourself in any of the categories listed above (please include if you are a student):
*
Your answer
Language abilities in English
*
A1 (Beginner)
A2 (Elementary)
B1 (Intermediate)
B2 (Upper-Intermediate)
C1 (Advanced)
C2 (Proficiency)
Listening
Speaking
Reading
Writing
A1 (Beginner)
A2 (Elementary)
B1 (Intermediate)
B2 (Upper-Intermediate)
C1 (Advanced)
C2 (Proficiency)
Listening
Speaking
Reading
Writing
Emergency contact - please give us details of a person we can contact in case of emergency (name, surname, phone number, email, relationship to you - e.g. mother, languages your emergency contact speaks
*
Your answer
ORGANIZATION INFORMATION: Please tell us about your ORGANIZATION, i.e., the (non-profit non-governmental) organization that you actively work/volunteer for, IF ANY). Please leave BLANK (empty) if you are NOT active in any non-profit non-governmental body]:
Name of organization
Your answer
Address
Your answer
Website
Your answer
What are your roles (volunteer, youth worker, board member, director ...) and your tasks? Please tell us how long you have been involved in youth work?
Your answer
Please describe your organization briefly. What are the objectives, main activities and target group of your organization?
Your answer
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