Application Form for Participants

Application Form for Participants

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SEYCOHAIDS CONFERENCE

Application Form for Participants

The Southern and Eastern Youth Conference on HIV /AIDS and Sexual Reproductive Health and Rights (SEYCOHAIDS) 2012, is organised by Global Hope Mobilization-GLOHOMO, in a partnership with the Malawi Government youth organizations, coalitions and networks, UN and governments working on HIV and Sexual and Reproductive Health of young people in Africa. The SEYCOHAIDS 2012 is made up of youths from SADC, EAC, ECOWAS, COMESA; other youth networks’ such as Global Youth Coalition on AIDS (GYCA), AfRiyan and African Forum on Science and Technology

Submit your application to before February 25, 2012

All the information provided will be treated with confidentiality. Completed application forms will only be shared with individuals who are in-charge of choosing delegates of the Conference. Incomplete application will not be considered for review

First Name:
Last Name(s):
Date of Birth (MM/DD/YYYY):
Country of Birth:
Home Address:
Country of residence:
Nationality:
I need a letter of invitation for a Visa / Yes ( ) / No ( )
Contact telephone: / Home: / Cell:
Gender: / Female ( ) / Male ( ) / Other ( )
I speak: (Language) / English ( )
Native:
Good:
Fair: / Russian( )
Native:
Good:
Fair: / German ( )
Native:
Good:
Fair: / Other ( ) Specify:
Native:
Good:
Fair:
Do you belong to any minority group or any key affected population? (optional)
Men who have sex with men ( )
Person living with HIV ( )
Person who use drugs ( )
Sex worker ( )
Indigenous ( )
Person with disabilities ( )
Others, Specify: ______
Personal Email(s):
Name of Organization or Institution:
Organization Address:
Website (if any):
Telephone #: Fax:
Email:
Organization history
What is your role in your organization:
Target population(s) you work with:
how long has your organizationexisted:
Description of work you do relating to HIV/SRHR : (max 200 words)
Do you belong to any networks? Yes ( ) No ( )
Which one(s)?
Have you participated in any regional or international conferences on HIV issues, Sexual and Reproductive Health or Youth programme? (Please Specify)
Have you participated in any previous International Conference on HIV/AIDS and SRHR? If yes, (Please Specify)
( (What are your area(s) of interest check all that apply)
( ) HIV / AIDS
( ) Gender
( ) Gay Lesbians Bisexuals Trans /Men that Have Sex with Men
( ) Stigma and Discrimination
( ) Harm Reduction and Drug Use
( ) Economics and HIV
( ) Youth-Adult Partnerships
( ) Voluntary Counseling and Testing
( ) Women and HIV/AIDS
( ) Human Rights
( ) Youth Leadership and Participation
( ) Participation of People Living with HIV/AIDS
( ) Indigenous Youth
( ) HIV/AIDS and its links to Sexual and Reproductive Rights
Others (specify)______
How is your participation going to benefit your community?(max 100 words)
How do you consider your experience on HIV and SRHR?
(This question has no bearing in relation to the decision of your application. Answering this question will help the organizers identify the type of sessions that it should give to suit the needs of the participants )
Very good Good Regular Little knowledge
What do sexual and reproductive rights mean to you?(max 200 words)
How are you going to fund your participation at SECOHAIDS 2012? (Registration, accommodation, Travel, feeding etc.) Please tick  one only:
  1. I will apply for a scholarship from SEYCOHAIDS 2012 ( )
  2. My organization will support my attendance ( )
  3. An agency or funder is supporting my participation ( )
  4. I will cover my own expenses ( )
  5. Other______

Why do you think you should participate at the SEYCOHAIDS Conference?
(max 200 words) what will you contribute at the SEYCOHAIDS 2012 Conference?
Do you have any special dietary requirements? Yes ( ) No ( )
If yes specify ______
For Emergency who to contact (next of Kin) Contact in your country:
Name : Telephone:
Did you submit proposal for workshop or session at the SEYCOHAIDS 2012Conference? If yes specify
Are there any other conditions or situations that you believe the organizers need to know to assist you before and during the Conference? Yes ( ) No ( )
If yes, please explain. (100 word)
Note: Please attach a personal recommendation letter from your Institution.
Before sending your application, re-name it as Myfirstname-mylastname.doc (. e.g. john-smith.doc)

REGISTRATION FEES

Delegates must register and pay online. We strongly urge all participants to register early to take advantage of the discount. Go to to register.

PARTICIPANTS / EARLY FEE:
25 January – 25 February, 2012 / REGULAR FEE:
26 February – 31 April, 2012 / LATE & ON-SITE FEE:
1 May – 6 June, 2012
Delegates
High Income Country
Low/Middle Income
country / USD 250.00
USD 100.00 / USD 450.00
USD 150.00 / USD 500.00
USD 200.00
Accompanying Person
Over 18
Under 18 / USD 200
USD 25 / USD 300.00
USD 25.00 / USD 300.00
USD 25.00

If you do not hear from us by March 25, 2012 consider your application unsuccessful

*List of developed countries according to the World Bank:

Andorra, Aruba, Australia, Austria, Bahamas, Bahrain, Barbados, Belgium, Bermuda,Brunei, Canada, Cayman Islands, Channel Islands, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Faroe Islands, Finland, France, French Polynesia, Germany, Greece, Greenland, Guam, Hong Kong, Hungary, Iceland, Ireland, Isle of Man, Israel, Italy, Japan, Kuwait, Liechtenstein, Luxembourg, Macau, Malta, Monaco, Netherlands, Netherlands Antilles, New Caledonia, New Zealand, Northern Mariana Islands, Norway, Oman, Portugal, Qatar, San Marino, Saudi Arabia, Singapore, Slovakia, Slovenia,South Korea, Spain, Sweden, Switzerland, Taiwan, United Arab Emirates, United Kingdom, United States, U.S. Virgin Islands.

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