 INSTITUTE
OF PROGRESSIVE COMMUNICATIONS
A project of Radio For Peace International
REGISTRATION FORM
PRINT,COMPLETE,SIGN,AND RETURN THIS FORM WITH YOUR
US$300.00 DEPOSIT.
PLEASE TYPE OR PRINT CLEARLY.
Mr. / Ms.
First Name______________________________________________
Last Name______________________________________________
Address____________________________________________
City___________________________
State/Province___________________
Postal Code_______________
Country_____________________
Telephone (home)___________________
Telephone (work)_____________________
Fax____________________
E-mail_________________________________
Passport number and country_______________________________
Birthdate (m/d/y)________________
Profession_________________________
Hobbies or interests________________________________________________
Do you wish to Spanish? Yes No
How much formal study of Spanish do you have? (if Spanish option is elected)
Semesters ___ Where?
Non-formal study?
Where?
When?
Circle one of the following:
(no Spanish) 1 2
3 4
5 (fluent)
Session requested:
(1st
choice: ) (2nd
choice: )
What is your motivation to study peace and peace journalism?
Please detail any experience you have had working in media.
PERSON TO CONTACT IN CASE OF EMERGENCY
Name____________________________________
Phone________________ Fax_________________
E-mail_____________________________________
How did you hear about IPC? Please give detailed information.
Please describe any health problems about which the IPC program director or your host
family should be informed (e.g. food restrictions, allergies, special medications,
physical limitations).
Please list any host family preferences (e.g. a non-smoking household, a family
with/without small children or pets, special dietary preferences, etc.).
I HAVE READ AND AGREE WITH THE GENERAL TERMS
OF IPC.
DATE__________SIGNATURE_________________________
IPC / RFPI
P.O. Box 3165
Newberg, OR 97132-3165
Tel: 011-506-249-1821 (Costa Rica)
Fax: 011-506-249-1095
info@rfpi.org |