Application form
2nd Regional Course on Minimum Initial Service Package (MISP-2) for Sexual and Reproductive Health
Time:25–29 April 2016
Venue: Bangkok, Thailand
Please send your completed application form with a copy of your resume to on or before 25 March 2016.
Date of application: ______
How did you hear about the course? Please check (√) your option:
( ) colleagues ( ) online information
( ) ADPC website ( ) professional association/network
( ) others, please specify ______
1. PERSONAL DETAILS
1. Full name(to be used in the course certificate)2. Title
( ) Mr.
( ) Ms.
( ) Dr.
( ) Other, specify:
3. NationalitySexDate of birth4. Marital Status
( ) Male(dd/mm/yy) ( ) Single
( ) Female( ) Married
5. Office addressTelephone number:6. Mobile number:
Fax number:E-mail:
7. Home address 8. Telephone no.:
9. Name and address of a person to notify in case of an emergency
10. Relationship
Telephone number:
11.English language proficiency 12. Food preferences
(Please tick where appropriate) ( ) Vegetarian
(E – Excellent, G – Good, F – Fair)( ) Non-vegetarian
( ) Other, specify:
Reading Writing Speaking
E G F E G F E G F
( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )
Please note that the course is delivered in English only.
Participants should be fluent in reading and speaking English.
2. EDUCATION, RELATED EXPERIENCE, AND CURRENT EMPLOYMENT
13. Education (Start with the last institution attended. Please use an additional sheet or refer to your resume, if necessary.)
InstitutionYear(s) attendedField of studyDegree
14. Current employment (Please attach your resume for more information about your employment history.)
15. Memberships of professional societies (Please use an additional sheet or indicate in your resume, if necessary.)
16. Give a brief description of your present involvement in professional activities related to the Minimum Initial Service Package (MISP) for Sexual and Reproductive Health in Emergency Settings and other emergency management work. (Please use an additional sheet, if necessary.)
17. Previous emergency management experience. (Please use an additional sheet, if necessary.)
18. Special interests in the field of MISP and emergency management.(Please use an additional sheet, if necessary.)
19. Previous course(s) on MISP/emergency management and related subjects attended.(Please use an additional sheet or indicate in your resume, if necessary.)
a)International courses (Give name[s] of course[s], duration and dates.)
b)Courses in your country
20. Previous international travel related to training courses, seminars, study tours, etc.(Please use an additional sheet or indicate in your resume, if necessary.)
3. OBJECTIVES FOR ATTENDING THE COURSE
21. Describe the practical use you will make of this course when returning home in relation to the responsibilities you expect to assume.(Please use an additional sheet, if necessary.)
4. COURSE PAYMENT
Tuition fees
The Course Package A costs USD1,575 without accommodation and includes course fee, daily meeting package with lunch and refreshments, a non-refundable registration fee of USD250, a training kit and all course materials.
The Course Package B costs USD1,995 and includes accommodation with international buffet breakfast, course fee, daily meeting package with lunch and refreshments, a non-refundable registration fee of USD250, a training kit and all course materials.
For local participants (Thai nationals only) the cost is THB15,000and includes the course fee, daily meeting package with lunch and refreshments, a non-refundable registration fee, a training kit and all course materials.
Please check (√) your option:
( ) Course Package A without accommodation
( ) Course Package B with accommodation
( ) Local participant (Thai nationals)
Note: Participants are responsible for all of their accommodation, travel expenses and incidentals such as medical insurance, laundry, personal phone calls, faxes, internet, and shipping of personal items.
Cancellation policy
If you are unable to attend, a substitute applicant is welcome to register in your place. Any course cancellation should be made 4 weeks prior to course commencement. Fifteen percent (15%) of the total tuition fees will be deducted for banking and administrative costs. No refunds will be made available for cancellations within 15 days before the course commencement.
Payment and bank details
The course fee can be paid in advance via bank transfer to ADPC’s account or deposited at the time of course registration in cash or cashier’s check/bank draft payable to ADPC. Please refer to the below bank details.
Account nameAsian Disaster Preparedness Center Foundation
Account number029-1-11600-0
Bank NameKasikorn Bank
Bank Address1019/18, PhaholyotinRoad, SamsenNai, Phayathai, Bangkok
10400, Thailand
Swift CodeKASITHBK
(Please include participant’s name in the "Originator to Beneficiary Information (OBI)" section of the wire transfer form.)
Who will pay for the course? Please check (√) your option:
Sponsor/employer ☐I will pay personally ☐
How will you or your sponsor/employer pay for the course? Please check (√) your option:
Via bank transfer ☐With cash ☐
With a cheque ☐Other (please specify): ______
Name of sponsoring organization:
______
Contact person: ______
Position title: ______
Address: ______
Email: ______
Telephone (please include international dialing code): ______
DECLARATION
I certify the above statements are true and complete to the best of my knowledge. If selected to participate in the MISP course, I commit to:
(a)Cancellations should be made 3 weeks (15 working days) before the start of the course.
(b)Conduct myself at all times in a professional manner as a representative of my organization and as a participant of ADPC’s course.
(c)Fully attend all course activities (provision of a certificate for the course is dependent on full attendance).
(d)Refrain from political, commercial or any activities other than those covered by the study program.
(e)Submit reports in accordance with my employer or sponsoring organization's requirements.
(f)Return to my country of origin at the end of the training course.
(g)Be fully responsible for any expenses (including medical) not covered as part of the course fee.
Signature of applicant:______
Date: ______
How to apply
To apply to the course, you are asked to fill in this course application form and submit it by email together with your resume to . If you have received the application from in a printed format, please return it to ADPC by fax or as a scanned copy.
Application deadline
The deadline of applications is 25 March 2016. Applications will be accepted on a rolling basis until the course is full, and you will be notified if you have been accepted to the course. Once the registration process has been completed, you will receive more information regarding the course and logistics.
For more information, contact:
Dr. Yvonette Serrano Duque
Senior Technical Specialist
Public Health in Emergencies
Asian Disaster Preparedness Center
Tel: +66 2 298 0681 (Ext. 400)
Fax: +66 2 298 0012
E-mail:
Thank you very much for your application and we will be in touch with you soon.
Page 1 of 6