Application Form: IGLYO Conference on Community Capacity Building for LGBTQ youth organizations

General Information

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* 1. Name and Surname (as in your passport)

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* 2. Preferred name (if applicable)

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* 3. Gender Identity

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* 4. Date of Birth

Date of Birth

Date

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* 5. Nationality

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* 6. Contact Information

Address: *

City/Town:

Postal Code:

Country: *

Email Address: *

Phone Number: *

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* 7. Do you have any accesibility or other requirements?

No

Yes (please specify)

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* 8. Do you have any special dietary requirements?

No

Yes (please specify)

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* 9. Do you have any preference regarding roommates, as far as gender?

No

Yes (please specify)

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* 10. Sending Organisation

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* 11. Contact Person (name, position and contact e-mail)

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* 12. Are you attending IGLYO's General Assembly 2011 as an official delegate from your organisation?

No

Yes (please make sure to register separately)