Application Form

Please ensure you complete all questions on this form to ensure you have applied correctly. All fields with an * MUST be completed. If you would prefer to receive a hard copy of the delegate application in the mail, please contact the Summit secretariat.
Title (eg. Prof/Dr/Mr/Ms)	*
Family name	*
Given names	*
Gender	Male Female
Date of Birth	*
Organisation	*
Position in Organisation
Organisation Website
Nationality	*
Postal Address	*
Suburb/Town
State
Country	*
Postcode
Telephone (work)	*
Telephone (home)
Facsimile
Email

1.	Please write a concise submission (up to two A4 pages) on one of the following:
	a) an issue or issues relating to the themes or topics of the Summit in your country or community. You may wish to consider the following: Are there any pressing needs relating to the themes in your community or country? Are there any particular causes and obstacles you can identify? Which of the workshops at this Summit are most likely to be helpful?
OR
	b) projects in relation to the themes or topics of the Summit you have been involved in, or other projects or services you are involved with which may be useful to other delegates.
OR
	c) ideas for one of the workshops

2.	Organisation(s) you will be representing, and a brief description of this organisation. Please include the following information: Your organisation's goals Year of your organisation's foundation How your organisation will be able to assist Summit development activities Resources you or your organisation may be able to offer to aid post-Summit action plans
	*

3.	What do you believe you could personally bring to the Summit?
	*

4.	Please indicate the following area which best defines your occupation *
	medical		community work
	government		allied health
	human resources		hospitality
	armed forces		architecture
	management		media/journalism
	marketing		engineering
	legal		science
	infrastructure		academia
	education		commerce
	information technology		other: please specify
	activist/lobbyist

5.	I would like my application to also be considered for a poster presentation.
	Yes	No

6.	I wish to be considered to receive funding support to help me attend the Summit.
	Yes	No
	Please advise in 75 words or less your reasons for seeking assistance:

7.	Which of the thematic areas would be of most interest/use to you and your organisation? Please indicate your preference, listing 1 - 4 (1 being first preference and so on).
	environment *	social capital *
	sustainability *	poverty*

8.	Which of the action area workshops would be of most interest/use to you and your organisation? Please indicate your preferences, listing 1 - 9 (1 being first preference and so on).
	housing and infrastructure *	food and agriculture *
	fresh water *	population and health *
	aid and trade *	education *
	appropriate technology *	transport *
	information and communication technologies *

9.	Do you wish to be considered as part of a team facilitating a workshop?
	Yes	No

10.	Please provide the name and details of a referee in your organisation, preferably your supervisor/employer, or the name and details of a person who can attest to your submission.

Surname	*
Given names	*
Organisation	*
Position in Organisation
Postal Address	*
Suburb/Town
State
Country	*
Postcode
Telephone
Facsimile
Email

If you have a friend, or know of an organisation, that may be interested in the Summit, please copy and paste the following link to this website and send them an email today! www.iyps.org

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