Epuka Ugaidi Organization Virtual P/CVE Training Registration Form

The Changing Dynamics of Violent Extremism in Horn of Africa

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* 1. First Name:

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* 2. Last Name:

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* 3. Age: Under 18 – parent/guardian consent required

18 - 22

23 – 27

28 – 32

33 – 35

Above 35

Under 18? (please specify)

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* 4. Gender:

Female

Male

Choose not to identify

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* 5. Phone Number: Please start with County Code eg (+254)

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* 6. Email address:

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* 7. Country of Citizenship:

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* 8. Country of Residence:

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* 9. Employment Status:

Employed

Self – employed

Unemployed

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* 10. How did you hear about this training?

Social Media

An organization

Word of Mouth

Other (please specify)

NOTE:

By applying to be a participant for Epuka Ugaidi training on “The Changing Dynamics of Violent Extremism in the Horn of Africa” you are consenting to the following:

1. I agree that, the information provided above will be held by Epuka Ugaidi ONLY as data and processed for statistical purposes;

2. I agree that, the outputs of the workshop will be shared to other researchers and interested professionals within the consortium;

3. I agree that, participation is voluntary, and I can choose not to participate in part or all of the project, and that I can withdraw at any stage of the project without being penalized or disadvantaged in any way;

4. I agree to the arrangements for data storage, archiving, sharing;

5. I agree to the use of anonymized quotes;

6. I agree to be kept updated with Epuka Ugaidi project activities and results through my contact above.