DESIGN, MANAGEMENT, AND EVALUATION OF COMMUNITY-BASED REPRODUCTIVE HEALTH PROGRAMS
August 18-29, 2008 In Nairobi, Kenya APPLICATION FORM DUE: July 21th 2008
First Name
Last Name
Organization Name
Position
Complete Date of Birth
Female Male
Are you proficient in English?
 Yes No
Contact Information  
Address
 
City
 Postal Code
Country
Tel/Work
Tel/Mobile
Fax
e-mail
Have you attended a Global Health Action-related Program/Workshop in the past? (Circle one)
If yes, please provide the location and date of the training.
Please describe the highest level of formal education that you have obtained.
Date
Institution
City and Country
Subject
Degree/Certification
  
Are you in a supervisory or management position? (Circle one)
Number of years in this role
Do you manage reproductive health activities or programs within your organization or institution? (Circle one)
(Circle one)
Funding Information: (Please choose one)
I have full funding from my government or a sponsoring agency. I will ask my sponsor to send confirmation of payment for my tuition, fees, and other course-related costs, excluding travel
I have partial funding from my government or a sponsoring agency in the amount of US $ (excluding travel).
I will continue to seek funding from government or sponsoring agency.
Sponsor's Name
Organization Name (if applicable)
Complete Mailing Address
 
City
Country
Telephone
Fax
Email
    
Method of Payment

Personal Statement: In the space below, please describe the reproductive health project you wish to implement after completing this course, as well as what you hope to accomplish through this course. You may attach additional pages if necessary. (Please attach Curriculum Vitae along with a letter from your employer stating your current position and responsibilities at the organization where you work)