<p> Massive Open Online Course (MOOC): Journalism for Social Change Application Form for the MOOC facilitated sessions</p><p>Motivated participants can register for the MOOC “Journalism for Social Change” at the following website: https://www.edx.org/course/journalism-social-change-uc-berkeleyx-j4sc101x# (Registration in this course is FREE). To take part in the facilitated sessions, please send:</p><p> the enrollment confirmation  this completed application by email to [email protected] with the subject line "MOOC – Journalism for Social Change" by October 16, 2015 at noon (Beirut time). Successful applicants will be notified of their selection to participate in the facilitated sessions offered by the Embassy in conjunction with this MOOC via email. Not selected? Don’t despair! You can still follow the MOOC online!</p><p>For more information, e-mail [email protected] or visit our website at http://lebanon.usembassy.gov/.</p><p>Deadline for submitting application information is October 16, 2015 at noon .</p><p>YOUR NAME Family First Middle</p><p>CONTACT INFORMATION</p><p>Home address:</p><p>: Mobile telephone: </p><p>: Home telephone: </p><p>: E-mail address: </p><p>PERSONAL INFORMATION</p><p>Gender: Male Female Date of Birth: Day / Month / Year Country/Countries of Citizenship: 1. Country of Birth: 2. </p><p>Country of Residence: City of Birth: </p><p>EDUCATIONAL BACKGROUND Please provide complete information about your educational background. (You may add additional rows if needed.)</p><p>Page 1 of 3 Institution Name Institution Location Dates Attended Major / Minor GPA (City, Country) MM/YY – MM/YY Fields College/University: From: To:</p><p>WORK EXPERIENCE (if applicable) Please start with your most recent position. You may include volunteer/extracurricular activities and internships. (You may add additional rows if needed.)</p><p>Name of Employer and Your Job Title and Responsibilities Dates of Employment Location MM/YY – MM/YY From: To:</p><p>From: To:</p><p>How did you know about this MOOC? </p><p>Are you engaged with any social media or civic engagement activities?</p><p>______</p><p>2 ESSAY (should be in English and no more than 250 words) use another sheet if required Why are you applying to attend the facilitated sessions associated with this MOOC and what do you expect to get out of them? Describe thoroughly how you will use the skills and knowledge that you will gain from this online course and its facilitated sessions?</p><p>Page 3 of 3</p>