Witness for Peace : Witness for Peace Travel Program Application

Basic Background Information

* First Name

Middle

* Last Name

* Current Mailing Address

* City

* State

* Zip

* Permanent Address

* City

* State

* Zip

* Day Phone

* Evening Phone

* Email

* Delegation

* Contact Me By
Phone
Email
No Preference

* Date of Birth

* Birthplace
(City, Country)

* Sex
Female
Male

* Passport #

* Exp.

* Occupation

* How long?

* How did you hear about this delegation?

Friend/Other:

Health and Emergency Information

Negative answers to the following questions will not necessarily prevent you from being invited to travel with WFP. This information will help us in assessing your special needs and allow us to take measures which would reduce the risks of serious health matters during the course of the trip. Providing false information will result in dismissal from the program and Witness for Peace is not responsible for health issues that may occur during the course of the trip.

* General Health
Excellent
Good
Fair
Poor

Dietary Concerns
(Please note that while there will usually be vegetarian options, vegan options are very difficult. Flexibility is necessary as it may be difficult to accommodate rigid dietary needs in areas where foods are difficult to get and local customs differ.)

List Here:

* Do you have any physical weaknesses, allergies, disabilities, illnesses that would impact your mobility on this delegation?
No
Yes

If so, please explain

* Are you currently under a physician's care or receiving prescribed medication of any kind?
No
Yes

If so, please explain

* Have you been hospitalized for an emotional or mental illness or treated for drug or alcohol addiction in the last two years? If so, are you currently under a physician's care or receiving prescribed medication for this condition?
No
Yes

If so, please explain

* Whom should we contact in case of emergency?
Name
Address
City, State, Zip
Phone (day and evening)
Email

Language Skills and Preferences

* Spanish
Fluent
Good
Fair
Poor

Other Language

Fluency
Fluent
Good
Fair
Poor

Please provide two personal references

* Reference #1
Name
Address
City, State, Zip
Phone
Years Known

* Relationship
Friend
Co-worker
Clergy

* Reference #2
Name
Address
City, State, Zip
Phone
Years Known

* Relationship
Friend
Co-worker
Clergy

Experience and Values

Please keep answers brief (up to 150 words).

* Do you have experience with human rights, social justice, environmental, or other organizations that are committed to social change? If so, please describe.

* How did you hear about Witness for Peace and why would you like to participate in the WFP Travel Program?

* Why do you want to travel with this particular delegation?

* Are you willing to adhere to a WFP policy of non-violence during this delegation?

If you are a member of a faith group, please list your faith and place of worship.
(Optional—This data is used to help WfP fundraise from certain progressive religious foundations.)

* Required Field