LIFELONG LEARNING PROGRAMME

GRUNDTVIG WORKSHOPS

Learner application form

Please send this application form duly completed and signed to:

- the organisation which organises the Workshop (Workshop Organiser)

Deadline for sending the registration form1: ………………..

If your candidature to this Workshop is accepted, the Workshop Organiser will return to you a signed copy of this form.

I - Identification of the Workshop1

Title of the Workshop
Host institution
Dates of the Workshop

II - Identification of the candidate learner

II.1. Contact details

Title (Mr/Ms)	First name
Family name
Address
Postcode	City
Country
Telephone 1	Telephone 2
Mobile	Fax
E-mail address

II.1. Other information

Date of birth
Nationality
Occupation (if applicable). If retired / unemployed: what former job did you do?
Special requirements for travels and/or during the stay (mobility, dietary, medical, etc…)
Experience with former international activities
Motivation to participate in this workshop	Max. 150 words
Languages spoken
Languages understood
Other information you would like to mention

II.3 Other questions (to be customised by the Workshop Organiser if needed)

CANDIDATE LEARNER

I confirm that I understand and intend to obey to the following principles and rules:

The Workshop Organiser will select candidates according to selection rules which have been approved by his/her Lifelong Learning / Grundtvig National Agency. These include rules on the minimum number of learners from a varied number of countries;

Candidates may be selected, rejected or registered on a reserve list;

The Workshop Organiser may consult the selected learners to organise their trips and accommodation;

By signing the present document, the candidate learner commits himself / herself to:

participate in only one Workshop throughout the EU within 3 years

if case of selection:

attend the Workshop

comply with all arrangements negotiated for his/her participation and to do his/her best to make the Workshop a success

fill in and sign a final evaluation form at the end of the Workshop and send a copy of it to the National Agency of his/her country.

in case of selection but non attendance: present evidence of force majeure,

in case of partial or non attendance and no presentation of evidence of force majeure, reimburse the Workshop Organiser of all costs incurred due to this non-attendance.

Your registration implies that you authorize the European Commission and the National Agency to make free use of the photographs, films and recordings bearing your image or voice in all type of publications, television broadcast or communications via the Internet for information or education purposes only. These photographs, films and sound recordings may be included and archived in the European Union’s online database, accessible to the public free of charge online.

Date: ………………………………………	Signature: ……………………………………………………………………

WORKSHOP ORGANISER

We confirm that the above mentioned candidate has been accepted to attend the following Workshop and will do our best to provide him/her with a successful experience, as described in our application form.

TITLE: ……………………………………………………………………………………………………………………………………..

DATES: ……………………………………………………………………………………………………………………………………

LOCATION: ……………………………………………………………………………………………..………………………………

Date: ………………………………………	Signature: ………………………………………………………………..…

1 To be pre-filled by the Workshop organiser

Coordinates of all National Agencies: http://ec.europa.eu/education/lifelong-learning-programme/doc1208_en.htm

And stamp of the organisation