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.