ADYNE application form: Media, a tool of social inclusion and truly inclusive information
Media & Inclusion: A seminar for youth leaders of the African Diaspora living in Europe
1st – 5th April 2013
Brussels (Belgium)


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GENDER (M or F)
NAME
SURNAME
STREET
POSTCODE
COUNTRY OF RESIDENCE
PHONE
FAX
MOBILE PHONE
E-MAIL
NATIONALITY
AFRICAN BACKGROUND/ORIGIN
DATE OF BIRTH
PLACE OF BIRTH
OCCUPATION
Visas - If you are accepted as a participant on this course, will you require assistance in obtaining a visa to Belgium? If yes, please indicate:
LANGUAGE SPOKEN
NAME OF ORGANISATION
A CONTACT PERSON WITHIN YOUR ORGANISATION
POSTAL ADDRESS
COUNTRY OF ORGANISATION
TELEPHONE
E-MAIL
FUNCTION AND POSITION IN YOUR ORGANISATION
WORKING LANGUAGES
Have you or your organisation applied for, or attended, any other seminar or activity organized by ADYNE?
EXPERIENCE OF MEDIA, SOCIAL INCLUSION AND YOUTH WORK
What is your motivation for taking part in this seminar? What do you hope to gain from it?
Any other relevant information or comments:
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