Meeting-Workshop
INFORMATION SOCIETY AND CULTURAL DIVERSITY IN THE CARIBBEAN
(CARDICIS)[1]
Saint Lucia - August 30th until September 1st -2004
Inscription Registration Card
(Latest date for handover, 12 august 2004 to Senaida Jansen, e-mail: )
1. IDENTIFICATION
1.1. Name:______
1.2. Surname: ______
1.3. Nickname: ______
1.4. Personal direction______
1.5. Phone (office): ______
Phone (home): ______
1.6. Fax (office): ______
Fax (home): ______
1.7. Email (office): ______
Email (private): ______
URL (office): ______
URL (private) ______
1.8. Sex: female____male _____
1.9. Age:______
2. ORIGEN Background
2.1. Country and city of origin current residence: ______
2.2. Name of place of birth (if different from 2.1): ______
2.3. Were you born in a rural or urban area? Rural_____Urban____
2.4. Specify your nationality(ies): ______
______
3. THE REGION KNOWLEDGE Knowledge of the Region
3.1. Are you currently living in a Caribbean country?
Yes_____ 3.2. Which one? ______
No ____ 3.3. Have you once previously lived in the Caribbean?
Yes 3.4. Which one? ______
No____
3.5. If you live in the Caribbean. Were did you live before, (omit) do you know other countries of the region?
Yes _____ (go to question3.8.)
3.6. If you have never lived in a Caribbean country, have you ever visited a country of the region?
Yes___3.7. Which one(s)?______
No _____ (go to section 4)
3.8. How did you get to know the country?
Work_____
Vacations ______
Family visit _____
Other reason (speciy) (specify) ______
4. FORMATION EDUCATIONAL BACKGROUND
4.1. What is your education level?
High school diploma ___ Bachelor’s degree___Master’s degree___PhD___
Technical diploma ___Other (please specify)______
4.2.Can you specify your professional educationProfessional qualifications:______
4.3.Language knowledge:
4.3.1. Indicate the level:
Fluent (F)
Very Good (VG)
Good (G)
Quite Good (QG)
A Little (L)
Not at All (NA)
4.3.2. Indicate which is your:
mother tongue and
the order of acquisition of each language (mother tongue is the first one)
Languages
/ Order of acquisition / Mother tongue / Read /Spoken
/ Written / CommentsCreole (specify the country)
French
Spanish
English
Other (s) (specify)
5. WORK
5.1. Name of the institution: ______
5.2. Your position: ______
5.3. What is your responsability responsibility at work: ______
5.4. Among your responsablilities responsibilities, do you have the opportunity to define or influence your institution institution’s policy or strategies?
YES___NO___
5.5. Explain how you can define or influence:
______
______
______
5.6. Is there any staff under your direction ? YES___NO___
5.7. How many women and men? women______men______
5.8. In which language do you communicate with your staff?______
6. TO ORGANIZE THE MEETING
6.1. Do you have any backup material (slides, pictures, posters, videos, case studies) related to the topics of the meeting, which you would like to share with the group?
YES ____ NO ____
(If yes, please describe briefly)
______
______
______
6.2. We will prepare a list of the participants with the following informations information: name, direction address, telephone, office and home fax, e-mail, institution name. Do you wish to be part of this list with all these informations this information given.
YES___NO___
6.2.1. If not, could you please write down the informations information you allow us to give (among the personal ones) (personal). The institutional informations information and the participant’s name, will remain on the list.
Personal direction Home address_____
Home telephone_____
Home fax____
Personal e-mail ____
6.3. Please, feel free to add any information or comment youconsider pertinent:
______
______
______
______
Thanks for your cooperation:-)
Saludos caribeños!!!
Information:
Senaida Jansen
Tel. (1.809) 537 2980 (in Dominican Rép.)
e-mail:
[1] Caraíbes, Diversidad Cultural and Information Society