Educational courses

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A. Name of the applicant requesting the funding
Name of applicant
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Job title
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Street
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Numberyour full name
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Cityyour full name
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State / Provinceyour full name
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Postal / Zip Codeyour full name
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Countryyour full name
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Phone Numberyour full name
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Short CV
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B. Proposed course or meeting
Is the person responsible for the project different to the person named in box A?
Name of person
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Job title
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Street
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Number
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City
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State / Province
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Postal / Zip Code
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Country
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Phone Number
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C. Background of the project – narrative summary
Title
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Sector in the area of contraception, sexual and reproductive health
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Comprehensive description
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When would it start / finish?
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Where will it take place – country / town, establishment?
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3 learning objectives
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Who will be the audience?
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What outcomes will be measured?
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Attach a planned evaluation form to be used by the participants to rate the speakers and course content.
Attach a planned evaluation form to be used by the participants to rate the speakers and course content.Attach a planned evaluation form to be used by the participants to rate the speakers and course content.
cloud_uploadChoose file
Attach the proforma you plan to use to evaluate the course from the organisers’ point of view.
Attach the proforma you plan to use to evaluate the course from the organisers’ point of view.Attach the proforma you plan to use to evaluate the course from the organisers’ point of view.
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Do you foresee any reasons (political, climatic, etc) why this project may be adversely affected?
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D. Financial related information
How much are you requesting from ESC?
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Are there other partners or organisations supporting this same course?
If YES - name the other partners who will support this course
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How much money is required for the course in total?
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Have you already obtained any funding or still awaiting a response towards this project?
Are you still awaiting a response towards this course? Give details below.
Items required for this courseTotal amount requested from ESC
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Name of partnersTotal amount requested from partner(s)
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Any commentsTotal amount requested from partner(s)
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Total amount requested from ESCTotal amount requested from ESC
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Total amount requested from partner(s)Total amount requested from partner(s)
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Add any additional information hereAdd any additional information here
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The ESC may not be in a position to fully fund all applications; you must indicate whether / how part funding may impact your course.more details
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Who will oversee the budget & keep accounts? Provide name, title, contact number and email addressmore details
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Note: The ESC retains the right to be refunded any unspent money from the grant.
E. Previous funding from ESC
If you or your department has received funding from ESC for a project or course before, please give details of the date of funding, contact person and title of project or course.more details
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F. Follow up
We, as responsible agents for this project, agree to the following 8 points:
First Name 1
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Last Name 1
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First Name 2
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Last Name 2
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Submission date of this form
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Questions? ESC Central Office: info@escrh.eu / Tel. 0032 2 582 08 52
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