Foundation for Self-Sufficiency in Central America

Application to participate in El Salvador Program

(Please print out and return to FSSCA, PRINT clearly)

Name:
Address:                                                                      City                 State      Zip
Phone: (home)                               (work)                                      (cell)
Email:                                                                          Birth date:
Citizenship:                                                                 Gender (M/F):
Passport:
Number                                   Issue place & date                               Expiration Date

Emergency Contact
Name:                                                                                      Relationship:
Address:                                  City                                                     State     Zip
Phone: (home)                          (work)                                    (cell)

Name of your group (if applicable):

Dates of your trip:
 

Spanish Language Ability
             Fluent       Conversational          Words/Phrases            None

Skills (please let us know about any skills or specialized knowledge you have that might be relevant to rural community development, environmental conservation, sustainable agriculture, radio, youth arts and theater)

Health

How would you appraise your health? Excellent Good Fair Poor
Are there any medical conditions that might affect your participation (disabilities, chronic illness, medication, allergies, respiratory problems, etc.)?          If yes, please detail below.

Diet

Do you have any dietary restrictions?

Although this application places no binding obligation on you or on the FSSCA, it does indicate a serious interest on your part to join the program. Should you decide to withdraw your application, please notify us immediately. Thank you for your interest and your time in filling out this application.

I have received, read and fully understand the Delegation Program Policies.
(Please initial): ­­_________

Signature:_________________________________________________________

Date:_________________________

Please return application to the FSSCA at the address below (print copies only, please).  Please include your $100 deposit.

The FSSCA will protect your private information & will not share it with anyone else.  We will use it to attend to your health and safety, and it will allow us to respond in a timely manner to any emergency that may occur.

FSSCA * 1904 Franklin St., Ste 902 * Oakland, CA 94612
510-835-1334  info@fssca.net