MEDIANE Thematic Encounters - Registration Form

Dear applicant,

Kindly complete this application before the given deadline (see question 1). You must fill in all the questionnaire.

If your application is valid at the end a message will annouce youthat your registration has been sent. PLEASE BE SURE TO READ THIS MESSAGE AT THE END BEFORE CLOSING THE APPLICATION FORM!

For your information, kindly note the following:

-- Questions starting with (*) are obligatory
-- Answers to questions with (**) in the end, may be published unless you send us a notification of refusal
-- Prepare a short biography of yourself and of your organisation before you start to include it in your application
-- Incomplete registration forms will not be considered

A confirmation of your participation will be sent at least 3 weeks before the enconter.

Thank you for your interest.

MEDIANE team

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1. Which MEDIANE Encounter are you applying for?
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2. Title on identification documents (passport or ID card) used for travel purposes
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3. Family name** (exactly as on passport / ID used to travel)
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4. First name** (exactly as on passport / ID used to travel)
5. Type of organisation
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6. Name of your organisation** (when applicable, write 'freelance')
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7. Position**
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8. Address
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9. Post code
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10. Town/City**
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11. Country**
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12. Telephone Number (please include the international dialing code but do NOT add the 00, plus sign (+), other symbols or spaces. Ex. for France: 3312345678)
13. Mobile phone number (please include the international dialing code but do NOT add the 00, plus sign (+), other symbols or spaces. Ex. for France: 3312345678)
14. Fax number (please include the international dialing code but do NOT add the 00, plus sign (+), other symbols or spaces. Ex. for France: 3312345678)
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15. E-mail address** (This address may be published for networking purposes - It will be your main email address of communication for the Council of Europe)

16. Other e-mail address, if any (This will remain private)

17. Website**
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18. Describe, briefly, your own professional background, your motivation for participating in this Encounter and explain how you can contribute to it. (~150 words)
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19. What are the main institution/s and/or media you are working for or collaborating with? Please describe the interest this Encounter represents for them and explain how they will benefit from your participation? (~150 words)
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20. With the aim of distributing a booklet presenting all participants and their organisation/media, we would like you to send us your photo and a logo of your organisation.

Please send these two images (jpeg. or gif. format) by e-mail to: mediane@coe.int**

All participants are asked to send (or resend) this picture and logo even if he/she already has been involved in a previous Mediane encounter ; this is available for all participants including partners and consultants.

If you fail to send the images, your application will be INCOMPLETE and WILL NOT BE CONSIDERED. When sending your picture and logo, please specify in your email the city of the encounter. THANKS!
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21. Organisation Biography in English and in French if possible (~100 words) **

This text will be published as you write it - Please do NOT write in caps and do not add bullets.
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22. Personal Biography in English and in French if possible (~100 words) **

This text will be published as you write it - Please do NOT write in caps and do not add bullets.
TRAVEL & DAILY ALLOWANCE - FOR NON CITY BASED PARTICIPANTS

The Council of Europe will provide the following to participants coming from outside the city where the encounter takes place:

i) when possible, a prepaid return ticket (ECONOMY only)
from your place of residence to the meeting location. your journey will be arranged according to the dates and times of the commencement and closure of the meeting. When flights are not available, you may be required to stay an extra night in which case the CoE will take this in charge, according to the conditions explained below.

ii) a perdiem of €130
(per night stay in a hotel) to cover accommodation (participants are asked to find accomodation directly) and non-covered lunches and diners. The total sum will be sent to participants by bank transfer after the encounter and on presentation of a duly filled-in reimbursement form together with a hotel bill.
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23. Indicate the city from where you will be leaving to reach the location of the meeting (this will also be the city for your return journey)
24. Special Travel dates

If you need to arrive before the day when the meeting begins or leave after the day it ends for justified personal or professional reasons, we will try to provide you with a ticket according to your needs. This is subject to availibility and budget and extra nights will be at your expense.

Please indicate the dates below:
DD MM YYYY
Outbound Departure Date:
/
/
Inbound Departure Date (RETURN):
/
/
25. Please note comments on your travel here, if any:
26. Do you have any special food requirements?
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27. Mother tongue:
28. Other language : Indicate competency on a scale of 1 to 5 (1 - excellent; 5 – basic)
29. Other language : Indicate competency on a scale of 1 to 5 (1 - excellent; 5 – basic)
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30. Material to bring

We encourage you to bring your own material and examples of diversity inclusiveness in media content from your practice. This may include reports, training tools, articles, audio-visual reports including TV, video, radio show in CD/DVD format and other media production. Your own or your organisation's ideas of how we can make media content production more inclusive are most welcome.

Please describe one or two examples of practices that you will bring with you and share with other participants at the encounter.

We thank you in advance for your active collaboration!

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31. Any products, resulting from this encounter, or produced by participants during the encounter, may be published and circulated by the Council of Europe and its partners for non-commercial use, and will carry a royalty-free license.
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