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APPENDIX OF APPLICATION FORM
FOR
Training to Strengthen Community-based Rehabilitation (CBR) through a Participatory Comprehensive Approach

Please submit all pertinent documents and your answers to this questionnaire in typewritten form
*This appendix is available at http://www.apcdproject.org/

TITLE Mr.
Ms.
Mrs.
Dr. 		NAME (captical letter)  
GENDER MALE
FEMALE 		FAMILY NAME GIVEN NAME MIDDLE NAME
BIRTH DATE (Day/Month/Year):

PASSPORT NUMBER:

PASSPORT EXPIRY DATE (Day/Month/Year):

HOME ADDRESS:

 

TELEPHONE NUMBER (Country Code/Area Code/Number):

FAX NUMBER (Country Code/Area Code/Number):

NAME OF THE ORGANIZATION:

 

ADDRESS:

 

TELEPHONE NUMBER (Country Code/Area Code/Number):

FAX NUMBER (Country Code/Area Code/Number):

 

E-MAIL ADDRESS:

Page break

DISABILITIES
(IF ANY)

YES.
NO.

TYPE OF DISABILITIES Physical Disability
Hearing Disability
Visual Disability
Intellectual Disability
Mental Disability
Other
  USAGE OF ASSISTIVE DEVICES: YES NO
DETAIL OF YOUR ASSISTIVE DEVICES:
  1. Power/electronic wheelchair ( Wet battery Dry battery)
  2. Wheelchair
  3. Crutch (es)
  4. White cane
  5. Other (                                )
NECESSITY OF A PERSONAL ASSISTANT FOR THE TRAINING:
  1. YES => (Details                    )
  2. NO
USAGE OF SIGN LANGUAGE (SL):
  1. English SL
  2. Other SL (                    )
NECESSITY OF A SIGN LANGUAGE INTERPRETER FOR THE TRAINING:
  1. YES => (Details                    )
  2. NO
DIETARY REQUIREMENT (IF ANY)

I hereby certify that all the provided information is correct, accurate and complete to the best of my knowledge.

In the event that I suffer injury, illness or death during the course of my participation in the program/course, I shall hold the Royal Thai Government, the Government of Japan, Japan International Cooperation Agency (JICA) and/or the Asia-Pacific Development Center on Disability (APCD) harmless and without any liability whatsoever for compensation towards myself, my legal representatives and/or my heirs. Should I cause any person loss of property, injury, illness or death during the course of my participation in the program/course, I shall be fully responsible and liable for the said person without reference whatsoever to the Royal Thai Government, the Government of Japan, JICA and/or APCD.

 

SIGNATURE OF NOMINEE

PRINTED NAME OF NOMINEE (________________________________)

DATE:

QUESTIONNAIRE

*Please submit your answers to the following questions as a part of the "Appendix of the Application Form. "

 

 

 

Name ……………………………………………………………………………………………………

Position …………………………………………………………………………………………………

Organization …………………………………………………………………………………………

Your roles in CBR project …………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………

  1. Q.1 What does “CBR” mean to you?
  2. Q.2 Please explain how community people have been encouraged to participate actively in your CBR Project.
  3. Q.3 What do you think about your CBR program? (Briefly explain its strengths and weaknesses.) What do you plan to do to improve the situation of your CBR program?
  4. Q.4 What factors do you think contribute to the success of CBR?
  5. Q.5 What do you expect to learn from APCD’s CBR Training Course ?

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