LABOR-RELIGION FAIR TRADE EYEWITNESS DELEGATION
PARTICIPANT INFORMATION DOCUMENT

Please print, complete and return this application and the separate HEALTH INFORMATION form to us by surface mail: International Project, Labor-Religion Coalition of New York State, 800 Troy-Schenectady Rd. , Latham, NY 12110-2455. Call us at 518/ 213-6000, ext. 6294 for more information. THANK YOU!

PERSONAL DATA

1. Name: ______________________________________________________
(exactly as it appears on your identification, please)

2. Address: _______________________________________

City: _________________________ State: __________ Zip:_________

3. Telephone: (day)_____________ (eve) ______________ (fax) ___________

4. Email: _______________________ 5. Cell phone: __________________

5. Date of Birth: ________________

6. School (if applicable): __________________________ Grade/Year: _____________

7. Passport Number:___________________________

Date/Place of Issue__________________________

8. Non-smoker: ________ Smoker: __________

9. Dietary needs: Vegetarian _________ Vegan:_________

Other special diet needs:___________________________________________

PLEASE NOTE: All dietary needs may not be able to be met. We will do our best to accommodate, but please be prepared with supplies of needed food items.

10. T-shirt size: small medium large x-large xx-large

11. T-shirt color preference: red blue black

PLEASE NOTE: Colors may be substituted depending on availability.

CONTACT INFORMATION

12. Emergency contact person: _________________________________________
This is the person we will call in the unlikely event of an emergency during the delegation.

Relationship to you: _____________________________________________

Telephone: DAY: _________________ EVENING: ___________________

CELL: __________________________

13. Personal Reference: _____________________________________________

Relationship to you: _________________________________________

Telephone: day: _______________ eve: ________________________

14. Delegation dates you are interested in: _____________________________
Is another time possible for you? _________________

AFFILIATIONS and PLANS FOR SHARING YOUR EXPERIENCE

15. Please list affiliations, communities or groups you belong to, schools, clubs, etc. with whom you will be sharing your experience when you return home:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

16. Please describe your plans for sharing your delegation experience when you return home:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

17. Please rate your comfort with understanding and speaking Spanish:

No comfort; no ability I understand a little
High school Spanish classes Understand a lot and speak some
Comfortable listening and speaking Fluent

SIGNATURE: _______________________________ DATE: ________ Rev. 10/08