Application » Philippine NGO Council on Population, Health and Welfare Inc.

Asia Pacific Conference on Reproductive Health
15 – 19 FEBRUARY 2001
Philippine Trade Training Center
Pasay City, Metro Manila, Philippines

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SCHOLARSHIP APPLICATION

Deadline for submission: 30 November 2000

The Asia Pacific Conference on Reproductive Health will be the first international gathering
of RH professionals throughout the region. The Conference aims to foster an exchange of ideas
and experiences among researchers, educators, service providers, NGOs and policy makers
from a wide range of Asian and Pacific nations to tackle the challenges and opportunities for
improving reproductive health policies and programs in the new millennium.

The information you provide in this form is considered confidential and will only be shared with the staff and organizer of the 1st APCRH for the purpose of reviewing and selecting scholarship
recipients. Scholarship applicants will be informed if they have been selected to receive a
scholarship by December 2000. The total number of scholarship available is limited. All applicants are therefore strongly advised to seek funding from other sources.

Applicants Information

Family Name
First Name
Organization
Address
Country
Telephone No.
Fax
E-mail
Courier Address (if different from mailing address)

SCHOLARSHIP OPTIONS: Not all your expenses to attend the Conference will necessarily be paid. In some cases, however, full financial support will be considered. Please indicate the support you actually need.
Registration Fee
Accommodation (shared or dormitory)
Air Travel (prepaid economy ticket)
Per Diem while in Manila

Questionnaire

1. Do you intend to apply for scholarship from other sources?
Yes No
2. Have you sought funding from other sources?
Yes No
3. Are you involved in any community based organization?
Yes No
4. How long have you been involved in the RH field?

5. Are you submitting an abstract for the APCRH?
Yes No (if yes, please click on the appropriate link that will be provided after submitting this form.)
6. Please indicate Gender
Male Female
Age
Below 20 21 to 30 31 – 40 41 – 50 50+
7. Do you have any restrictions concerning mobility, nutritional needs or health.
Wheelchair Sign Language Vegetarian Food Others (Please Specify)
8. Are you involved in any of the following advocacies?
Maternal and Child Health Prevention and Control of RTI/ STDs/HIV/AIDS Adolescent Sexual and Reproductive Health Prevention of Abortion and Management of its Complications Family Planning Men’s Reproductive Health Prevention of Reproductive Tract Cancer and other Gynecological Problems Counseling and Education for Human Sexuality Infertility Management Interventions for Cases of Violence Against Women Care for the Elderly

9. State the different ways you will share the knowledge acquired during the APCRH when you return to your country/community.

10. Give reasons why you feel you should receive Conference Scholarship.

11. Are you willing to share accommodation with other participants?
Yes No
12. Please indicate the city and country of the international airport from where you are to depart to Manila if different from your address.
City
Country
13. Do you hold a valid passport? Yes No
If yes, please complete the information below.

Country of passport
Passport number
Date of issue (dd / mm / yy)
Place of issue
Date of expiry (DD / mm / yy)
Name as it appears on the passport
Family Name
First Name

* Please determine if you need a visa to enter the Philippines. If so, please obtain a visa application and be prepared to submit it if you receive a scholarship.

Application Guidelines

This application form must be received by 30 November 2000. Send in your application as early as possible. Applications that are not complete or are received after 30 November 2000 will not be accepted. APCRH Scholarship Committee Philippine NGO Council on Population, Health & Welfare, Inc. # 38-A San Luis Street, 1300 Pasay City PHILIPPINES The Conference will not provide financial assistance to delegates who arrive at the Conference without a confirmed scholarship award. By clicking on the submit button the applicant thereby agrees to the declaration below. I hereby undertake to immediately advise the APCRH if I am awarded sponsorship from other donors which duplicates any of the support I have requested in this form. I understand that failure to do so will result in cancellation of any support awarded to me by the Conference Scholarship Committee.