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APPLICATION FORM LET’S MAKE A PEACE BRIDGE IN JAPAN!
* This application form and the other attached documents you will submit to the NGO “Helping Children in
the Holy Land” are confidential and will be reviewed only by the committee of selection of the NGO.
Please send the completed form by the 22nd February to the following email addresses;
TO: Hiroko Inoue: [email protected] Yacoub Ghazzawi [email protected]
CC: Fr. Ibrahim Faltas [email protected]
APPLICANT INFORMATION
Your Answer
Family Name
First Name
Middle Name
Gender M / F
Place of Birth
Date of Birth
Nationality
Religion
Home Address
Telephone No.
Mobile No.
Mobile No.
Email Address
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Skype Account
Type of Passport
Passport No.
Place of Issue
Date of Issue
Date of Expiration
ID No.
Occupation
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EDUCATIONAL BACKGROUND
High School/Univ. City/State Grade Major Years Degree
LANGUAGES
Languages Native Excellent Good Fair Poor
English
WORK/VOLUNTEER EXPERIENCES
Position Name of Organization Period Tasks
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SKILLS/EXPERIENCESPlease indicate if you have any special skills/experiences that can contribute to the volunteer and cultural exchange sessions (i.e. music, performance, cultural lessons, etc.)Answer:
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QUESTIONS
1. How did you know and what did you hear about the “LET’S MAKE A PEACE BRIDGE IN JAPAN” Project?Answer:
2. This project focuses on interaction among Israeli, Palestinian and Japanese youth. What are your motivations and why do you think you are the right person to participate in this project? Elaborate.Answer:
3. Describe yourself, your personality, your relationship with your family and with the people around you? Answer:
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4. What is your idea about how to live in peace in your community of in your country? What is your dream for the future, etc. Elaborate. Answer:
5. As an Israeli/Palestinian youngster, what is your perspective concerning the ongoing conflict and its resolution? Elaborate.Answer:
6. How can you become a peace builder and peace messenger in the future? Please describe your wish, or your dream or concrete planning, or determination, if you have. Elaborate.Answer:
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ABOUT YOUR HEALTH
Questions Yes No
1. Do you have a chronic or recurring illness/condition?
2. Have you had any illness or infectious disease recently?
3. Do you have any allergy? (medicines, insects, foods, etc.)
4. Do you have diabetes or asthma?
5. Do you have any dietary restrictions? (medical, religious, etc.)
* Respecting our diversity and community life, the Project will take your religious and allergic dietary restrictions into consideration, but not your personal preferences. In addition, the Project is not capable of providing vegan or strictly kosher meals.
Q: If you answered “yes “ to any of the above questions, please explain: _______________________________________________________
Q: Blood type:_____/RH____
ABOUT THE “ONE DAY DEAD SEA EXCURSION
The Project proposes you as a first contact with us,“ONE DAY DEAD SEA EXCURSION” (Please see the p. 4 of the Guidelines “Selection”)
(3rd March, 2018) (Participation Fee : NIS 100)
I join this program. YES / NO (Please check.)
ABOUT THE SPECIAL PROGRAM in Japan
The Project proposes you also a special and supplementary program, “2 DAYS EXTRA EXPERIENCES OF JAPANESE CULTURE TOGETHER”
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(20th & 21st August, 2018) (Supplement Fee: US$ 60)(Please see the p. 4 of the Guidelines “Selection”)
I join this program. YES / NO (Please check.)
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ABOUT THE COLLABORATION IN THE FUTURE
1. You are requested to continue to be part of Peace Bridge activities after the project.* Participate in exchange programs, meetings, activities after going back to your country.* Participate in exchange programs, meetings and activities for Japanese study tour group in March 2018
2. We may ask you to host Japanese student(s) at your home upon their visit.Is your home able to host the students (accommodation and meals)? YES / NO
If you answered YES to the above questions, how many guests can you host at your home, and which gender?
Answer:
Signature: _______________________________
Date: _______________________________
Please attach a copy of your passport and a photograph.
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