Amizade Participant Information
Thank you for your interest in serving and learning with Amizade and our global network of community partners. Please complete the following questions. The information you provide allows us to register you for your appropriate VSL program and helps us better understand our community and who is accessing our programming. Please contact the Amizade office at 412-586-4986 or support@amizade.org for any questions.
What type of program are you applying for?
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Group Program
Open Group Program
Individual Internship
Group Program
If you are not in a group program, skip this section.
What is your group program number?
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Open Group Program
If you are not in an open group program, skip this section.
Open Group Program Number
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Individual Internship
If you are not doing an individual internship, please skip this section.
Where are you interested in interning?
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What are your ideal start and end dates?
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Name
First Name
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Last Name
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Birthdate
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Gender
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Male
Female
Other
Email
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Mobile Phone
Can we text you?
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Yes
No
Current Address
Street Address
City
State/ Province
ZIP/ Postal Code
Country
Demographics
This information is used for statistical purposes only and will not be used as a basis for discrimination.
Ethnicity
White (non-Hispanic) or Euro American
Black, Afro-Caribbean, or African American
Latino or Hispanic American
East Asian or Asian American
South Asian or Indian American
Middle Eastern or Arab American
Native American or Alaskan Native
prefer not to respond
Other
Annual Household Income
< $20,000
$20,000 - $40,000
$40,000 - $60,000
$60,000 - $80,000
$80,000 - $100,000
$100,000 - $150,000
$150,000 - $200,000
>$200,000
Which of the following best describes your home community?
Urban
Rural
Suburban
Other
Do you currently have a passport?
Yes
No, I do not currently have one
No, but I have applied for one
Passport Issuing Country
Educational / Occupational Information
Are you currently a student?
Yes
No
If yes, please indicate your Current Academic Status:
5th or 6th grade
7th or 8th grade
High School Student
High School Graduate
1st year university student
2nd year university student
3rd year university student
4th year university student
Bachelor's Degree
Master's Degree
Doctorate
Other
What is the highest degree or level of school you have completed? If currently a student, highest degree received.
No formal schooling
Primary school to 8th grade
Some High School, no diploma
High School Graduate, GED or equivalent
Some college credit, no degree
Trade/ technical/ vocational training
Associate degree
Bachelor's degree
Master's degree
Professional degree
Doctorate degree
Other
Do you identify as a first generation college student or graduate?
Yes
No
Other
Current Employment Status:
Part-time employment
Full-time employment
Self-employed
Not employed, but looking for work
Not employed, and not looking for work
Other
Have you participated in an Amizade program before?
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Yes
No
If yes, which Amizade sites did you visit and in what year?
Do you speak a language other than English?
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Yes
No
If yes, which language(s) and what is your proficiency level
How did you hear about Amizade?
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Current or Past Participant
Friend/Family
Amizade Staff Person
School
Media/News
Facebook, Twitter, or Linkedln
Google, Bing, Yahoo, or other search engine
Other Internet/ Website
The Global Switchboard
Other
If you were referred, who referred you to Amizade?
What is your interest in this program?
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Health and Medical Information
The purpose of this form is to help Amizade be of maximum assistance to you before and during your Amizade Program.
How would you describe your personality?
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Introverted
Extroverted
Other
What makes you nervous about this experience?
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Is there anything would like to share with your program facilitator about your physical or mental health that might affect your participation?
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Emergency Contact Information
First Name
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Last Name
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Relation
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Phone
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Privacy Policy
For more information about our Privacy Policy, please visit the this page: https://amizade.org/privacy-policy/
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I agree to the terms and conditions outlined in Amizade's Privacy Policy.
Submit
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