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ENGLISH CLUB MODERATOR TRAINING

(ECMT)
ANTSIRABE - FIANARANTSOA
MARCH 11-12, 2024
Application Form

Deadline: Friday, 23 February 2024

1. Last name / Family name / Surname

2. First name

3. Please confirm below the name you would like to appear on your name tag during the training.

4. Please confirm below the full name you would like to appear on your certificate of participation.

5. Gender
☐ Male ☐ Female
6. Date of birth (day/month/year)

7. Email address

8. Home address

9. Phone number

10. Facebook ID

11. What is the name of the English Club you are a member of? Where is it located?

12. What is your responsibility within your club? (Specify your title)
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13. Complete the following information about your English Club?

- Creation Date:
- Number of Members:
- Number of Moderators:
- Meeting Location:
- Activities:

14. What challenges have you experienced as a moderator/leader of your English Club?

15. How did you address these challenges?

16. What do you expect to receive from this training for English club moderators?

17. Training experience

☐ I am a U.S. Government program alumni ☐(please specify the program)_____________________________

☐ I am currently following a U.S. Government program ☐(please specify)______________________________
☐ This is the first U.S. Government program I am attending

18. Please confirm by ticking the boxes:

☐I will comply with the 100% attendance policy of the two-half day training scheduled for March 11-12, 2024.
☐I commit to attending the workshop without transportation support.