Application Form

2011 Asia Pacific Regional Blind Medical Massage Instructors' International Training Program
(Changsha, China from April to May, 2011)

Application Form (Typewriting or block letters)

(Country )                                                       
(Name of nominating organization/institution/company)
                                                                                        
(Name of Nominates):                                                        
(Name of applicant) :                                                         
to the WBUAP Medical Massage Instructor’s Training Course for the Blind, April 1st – May 31st, 2011.
Reasons for nomination (obligatory):

_________________________________________________________________________________
_________________________________________________________________________________

Signature of nomination organization/institution/company_______________________
Date_______________________
(When necessary/applicable)
The Nomination is approved by (name of authorizing authority):

In accordance with local rules .
Signature of authorizing authority :____________________________________                                     
Date :_______________________

The Application SHOULD be submitted to the WBUAP Medical Massage Instructor’s Training Course for the Blind Organizing Committee at the latest on November 30, 2010.

Mailing Address:

Hunan Yeahcome Health Care Co., Ltd
Add.: 7F Huatian Xincheng, No.89 Furong Zhonglu Erduan,
Changsha, Hunan, 410011 China
Program Director: Mr. Peng Lei

Tel: +86 731 84899 333 ext. 8811  Fax: +86 731 8489 8056
Website: www.blindmassageintl.com  E-mail: penglei@yeahcome.com
PERSONAL HISTORY  First Name

 Date of Birth
(yy-mm-dd) Second Name
Passport No.
Family Name
(surname)  Telephone (office)
Sex (M/F) 
Mobile
Country
Fax
Nationality
E-mail(s)
Office Address
Name of person to be notified in case of emergency :
Full Name
Telephone
Email
Education
Name of Institution (University) and Palce of Study  
Major fields of study
Years of study from-to
Degree obtained

EMPLOYMENT RECORD

A. PRESENT POSITION 

Title of your post 
Years of service: from-to: xx xx From                to
Type of organization
Name of Supervisor (if any)
Name and Address of Employer  
Description of your work, including your personal responsibilities

B. PREVIOUS POSITION
Title of your post
Years of service: from-to: xx xx From                to
Type of organization
Name of Supervisor (if any)
Name and Address of Employer
Description of your work, including your personal responsibilities

QUESTIONNAIRE
Your present Organization                                   
A) Name of organization                                           
B) Total number of staff members.           persons,
C) Including            persons with visually impaired

 Are you visually impaired? Yes         No
If your answer is “Yes”, please answer the following questions…
Please describe your eye condition.
Totally blind                 Low vision 
(Eye sight :  Right Eye                 Left Eye             )
The cause of your visual impairment :                               
Usually you use
Printed materials         Braille materials For reading   
You can read normal printed materials with your naked eye. You can read normal printed materials with magnifying glass / lens.
You can read large print letters. You can not read printed letters. Choose how you see in your daily life. You can ride a bicycle. You can walk around an unfamiliar place without a white cane.
You need a white cane to walk. You can walk alone in daylight, but need a white cane at night time.
 
LANGUAGE CAPACITY
English certification does not have to be carried out if any of the following is applicable.
English is my mother tongue or official language of the country
English is my working language (please enclose statement from management) ()
Carried out higher academic education (min 6 months) where English was the medium of instruction (please enclose copy of certificate)

ABILITY TO UNDERSTAND
Understands without difficulty when addressed at normal rate
Understands almost everything, if addressed slowly and carefully
Requires frequent repetition and/or translation of words and phrases  ABILITY TO SPEAK
Speaks fluently and accurately and is easily intelligible
Speaks intelligibly, but is not fluent or altogether accurate 
Speaks haltingly, and is often at a loss for words and phrases
ABILITY TO WRITE
Writes with ease and accuracy
Writes slowly and with only a moderate degree of accuracy
Writes with difficulty and makes frequent mistakes  READING ABILITY AND COMPREHENSION
Reads fluently, with full comprehension
Reads slowly, but understands almost everything Reads with difficulty, and only with frequent recourse to a dictionary

MEDICAL STATEMENT

Please check the relevant boxes  I do not have any infectious diseases (for example tuberculosis or trachoma) or any other illnesses which could present risks to persons that I will come in contact with.  I do not have any medical conditions which prevent me from carrying out training away from home.
I am in good health and enjoying full working capacity.
Comments I have a Health Certificate

Culture and dietary habits
(Please write down your habits of culture and dietary)
Taboo:

Dietary:   Halal  Chinese Food  Western Other habits:

Information to all applicants:
Upon confirmation that your application has been accepted, the personal information that you have given in this application will be used by the Program Organisers in administering the Program. The data will not be used for other purpose.

Signature of Applicant 
I certify that my statement in answer to the foregoing questions is true, complete and correct to the best of my knowledge and belief. If selected as a participant I undertake to spend the time during the period of the Program as directed by the Program management.
Signature of Applicant                          Date _______________________