<p> (all information gathered in this application form is held in strict confidence and is only used by the organizer for organizational purposes, or for final reports as statistics)</p><p>Read the questions below Fill in the answers in this column</p><p>ArtichokEVS Syncro – Synergy Croatia 1st September – 30th November 2015 First Name: Surname: Address: Zip code: City: Country: E-mail: Date of birth: Gender: ID number: Name of the sending Associazione Culturale Eufemia organization: Pasquale Lanni Name and e-mail of the EVS [email protected] coordinator in your sending organization: Level of English (excellent, good, medium, bad):</p><p>What other foreign languages do you speak? What is the level? Contact person in case of emergency: Address: Phone number: Relation to you: Have you participated in any International Exchange, Training, Seminar, Scholarship or other international project before? What do you do for a living? What is your profession? What hobbies/interests do you have?</p><p>Why do you want to participate in ArtichokEVS? (min 100 words)</p><p>Why do you want to do your EVS service with Syncro? What do you expect to get out of it? (min 100 words)</p><p>What is it that you’re best at and what are you worst at? (min 100 words)</p><p>Health Condition </p><p>Do you have any disabilities (mental/physical)? If yes, please specify your diagnosis and symptoms. Do you have specific health or other problems, which could affect your EVS?</p><p>Do you have any allergies? If yes, please specify.</p><p>Do you have a special diet? If yes, please specify.</p><p>Do you take any medication? What for?</p><p>Did you have any serious medical problems in the past?</p><p>ADITIONAL INFORMATION</p><p>Are you unemployed? Yes No</p><p>Do you have low income or Yes No low living standard? Do you have learning Yes No difficulties? Do you belong to any Yes No national or ethnical minority? Do you have any geographical Yes No obstacles? (coming from rural or isolated areas, from areas where public services are lacking?) Are you coming from a Yes No broken family? Are you coming from a foster Yes No home? Do you belong to sexual Yes No orientation/gender minority group?</p>