Young PFDJ Conference Registration Form
Personal Information
First Name Last Name Eritrean ID #
Mother Tongue Date of Birth Place of Birth Gender What languge(s) do you speak?
Address
Street Address City
State Zip
Country E-Mail
Phone:
Home Cell  
 
T-Shirt Size  
Level of Education  
Field of Study  
Emergency Contact
Full Name
Relationship to Participant
Home Phone Work Phone
Previous Participation
Participation at the 1st YPFDJ-Conference? Yes:
No:
Participation at the 2nd YPFDJ-Conference? Yes:
No:
Participation at the 3rd YPFDJ-Conference? Yes:
No:
Participation at the 4th YPFDJ-Conference? Yes:
No:
Participation at the 5th YPFDJ-Conference? Yes:
No:
Topics Of Interest:(select all that interest you)
Movement Building/Organizational Development
Communications Media/Media Justice
Recruitment & Retention Fundraising
Other  
Personal & Social Development
PFDJ/Eritrean Values Leadership Development
Other  
Nation Building & National Development
Economic Development Environmental Justice
Political Stability Human Development
Health Women's Issue
Education Other
Transportation Information
Arrival Date & Time:
Arrival Point:
Arrival by plane, car, train?
Departure Date & Time:
Departure Point:
Departure by plane, car, train?
Special Needs Please disclose any condition, limitations, or needs which might affect your ability to fully and successfully participate in the conference indoor/outdoor activities in a remote setting. Any allergies to insects, plants, food, or medications and any medication you currently are taking.
Agreement I have read and understood the Rules and Regulations and I will abide by them during the 7th YPFDJ-NA conference. The above information is true to the best of my knowledge.