Application for Hope

For Uni
Directions: Please type or print clearly, and fill in all blanks.

Deadline: Completed application form and other supporting documents must be submitted to HAN

Attach your photo here

Contact Information

Information about Affiliation

Prefered Address

Language Proficiency

How did you learn about

HANDs! Project?

Oversea Travel / Study

Experience (if any)

Oversea Travel / Study

Experience (if any)

Briefly explain about yourself,

including your background,
personality, as well as your
volunteer / internship /
professional experience.
Please focus on what are
related to the HANDs! Project.
(750 words maximum)

Briefly explain about your

experience in communitybased activities, preferably
disaster-related activities (500
words maximum)

Give us your experience in creative thinking and taking action. We define "creative" as "to th
situation and you performed your creative thinking to solve the problem. The situation could be
and do-er yo

In the HANDs! Project 2015, the participants are expected to create a disaster education rela
related program that will benefit local communities and that you would like to create. Please sp
tell us how you will contribute in rea

I hereby certify that all the information given above is nothing but the truth.

Signature*

Date

(* If you are submitting this form by email, paste electric image of your signature in case that it is n

(* If you are submitting this form by email, paste electric image of your signature in case that it is n

Please attach to this application form the following documents

1. Curriculum Vitae in English. This must not exceed 2 pages in length.
2.Any additional materials about your disaster related activities

Application for Hope and Dreams (HAND

For University Students

or print clearly, and fill in all blanks.

plication form and other supporting documents must be submitted to HANDs! Indonesia Secretariat, by 13:00
First Name

Name

Sudarman
dd/mm/yyyy

Date of Birth

8/10/1990

Country of Birth

Indonesia

Current Home Address

Jl. Panorama No.8 Kecamat

Mobile

082-292-498-415

University or Graduate School

Haluoleo University
Address

Please indicate which address you would lik

( ) at home ( ) at uni
English Proficiency Certification (if any)
Type
( ) From The Japan Foundation, Jakarta's Facebook
( ) From The Japan Foundation, Jakarta's Twitter
( ) From The Japan Foundation, Jakarta's Website
() From a Friend
( ) Others

1. Leader Team of Celebes Summit Expedition that held by Ischiadicus Medical Emerg
team "Ekspedisi Nusantara Jaya 201

1. Leader Team of Celebes Summit Expedition that held by Ischiadicus Medical Emerg
team "Ekspedisi Nusantara Jaya 201

I'm an open minded person, I always wonder to learn something new. I always dream th
being that live here. I realy excited to discover new experience, travelling and give co
was i give from the creator of universe. and of course it's our duty to take care of thi
happy. actually i really happy to describe about earth until i forget to talk about my se
really bussy. but i always give some a break to talk about my organisation. i'm an activi
after i finish my study, i'll be active as a doctor and join to the global environment or
really love this natu

On flooding disaster that attack kendari on july 2013, I stand by on emergency cam
emergency medical team I active to communicate w

nce in creative thinking and taking action. We define "creative" as "to think out the of the box" to provide
med your creative thinking to solve the problem. The situation could be from your design work, communit
and do-er you are. (750 words maximum)

2015, the participants are expected to create a disaster education related program as a group, that will b
ll benefit local communities and that you would like to create. Please specify 1) your target population, 2)
tell us how you will contribute in realizing the project. Be creative! (75

e information given above is nothing but the truth.

Date

is form by email, paste electric image of your signature in case that it is not possible, just type your name.)

is form by email, paste electric image of your signature in case that it is not possible, just type your name.)

cation form the following documents

glish. This must not exceed 2 pages in length.

s about your disaster related activities

Dreams (HANDs) Projects

ty Students

nesia Secretariat, by 13:00 (WIB), Monday, July 13, 2015 by e-mail

st Name

Middle Name

Family Name

darman

mm/yyyy

Age (as of July 13, 2015)

10/1990

donesia

24

Sex

Citizenship

Indonesia

anorama No.8 Kecamatan Sabilambo, Kabupaten Kolaka, Provinsi Sulawesi Tenggara

Telephone

E-mail

gigabytemaman@yahoo.com

Major

Medicine

Faculty

Medicine

Batch
Telephone
Fax
E-mail
address you would like to use for correspondence:

( ) at home ( ) at university

on (if any)

English Level
Score

( ) Fluent () Fair

( ) Poor

iadicus Medical Emergency Team Medical Faculty of Haluoeleo University, 2. Chief of medical
isi Nusantara Jaya 2015" Chapter Makassar

new. I always dream that one day, I can give I huge contribution to help this earth and human
, travelling and give contribution to the earth. in my mind the place that we called as "earth"
duty to take care of this earth, to make earth happy and everlasting. the earth happy and all
et to talk about my self. Now I'm a coassistant student of Haluoleo medical faculty. everyday i
anisation. i'm an activist of ischiadicus medical emergency team. i always wonder that one day
global environment organization like greenpeace or earthhour. i'm also a mountain climber i
really love this nature.

d by on emergency camp to help the refugees. And as the team commander of ischiadicus
tive to communicate with the other disaster organisation.

he of the box" to provide solution. Tell us about your own experience that you faced to a problematic
r design work, community-based activities, organizing events and others. Show us how creative thinker
50 words maximum)

am as a group, that will be implemented in 2016. Please explain your ideas about disaster education
our target population, 2) knowledge to be used, and 3) how to transfer/convey/communicate it. Please
project. Be creative! (750 words maximum)

le, just type your name.)

le, just type your name.)

Family Name

( ) M
( )F
Indonesia

Sulawesi Tenggara
gigabytemaman@yahoo.com

Medicine

Medicine

nglish Level

t () Fair

( ) Poor

iversity, 2. Chief of medical

to help this earth and human

ce that we called as "earth"
ng. the earth happy and all
o medical faculty. everyday i
i always wonder that one day
m also a mountain climber i

ommander of ischiadicus

t you faced to a problematic

s. Show us how creative thinker

eas about disaster education

convey/communicate it. Please