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mPowerArt - Registration Form
ERASMUS+ Youth Exchange
11th - 17th September 2021 (10th and 18th travel dates)
Ludbreg, Croatia
http://udruga-lumen.hr/mpowerart/
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* Indicates required question
Email
*
Your email
First Name
*
First name as on your passport
Your answer
Family Name
*
Surname as on your passport
Your answer
Nationality
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Gender
*
Choose
M
F
Other
If you need Visa for Croatia we will send you invitation letter. In order to do that, we will require your passport number:
Your answer
Home address (Street and number)
*
Your answer
Postal code
*
Your answer
City
*
Your answer
Country
*
Your answer
Phone (preferably mobile)
*
with full international dial codes
Your answer
English
*
(1-basic, 2-good, 3-very good, 4-fluent, 5-mother tongue)
Basic
1
2
3
4
5
Mother Tongue
Do you have any special needs or requirements that the host organisation should know about?
E.g. mobility, medical needs, mental health issues, allergies, dietary restrictions
Your answer
Please indicate us the name and full contact details of a person to be contacted in case of emergency during the course (name, surname and phone number)
*
Your answer
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