Leadership Camp Registration Form

I. PERSONAL DATA
Name*
Mr.Ms.
Last NameFirst NameMiddle Name
PERMANENT MAILING ADDRESS
Please note that we are going to use your contact information for all correspondence, so please be detailed as possible
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Mobile Number (please specify your area code )*
Emergency Phone Number ( Compulsory )*
E-mail (compulsory)
Birth Date*
DayMonthYear
Birthplace*
Native Language*

II. HEALTH
Do you have any physical limitation or impairment?*
yesno
If yes, please specify:
Have you ever had any major illness?*
yesno
If yes, please explain:
Do you have any alergy?*
yesno
If yes, please explain:
What kind of food that you can not eat? *

III. Family Data
A. Father
Name*
First NameLast Name
Education
Occupation
Company/Institution
B. Mother
Name*
First NameLast Name
Education
Occupation
Company/Institution

IV. Background
In this box please tell us about your personal life and your family. THIS STATEMENT IS AN IMPORTANT PART OF YOUR APPLICATION*

V. Educational Information
SUMMARY OF EDUCATION*
Year of enterd Year of graduated Name of school
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Course / Training (attach evidence if any, e.g; certificates/reports. Write NONE if you don't have any)*
Name Institution Year (from - to) Result
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Extra-curricular activities (attach evidence if any. Write NONE if you don't have any)*
Activity Institution/Organization Year (From - to)
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Organizational Activities / Community involvement. (attach evidence if any. Write NONE if you don't have any)*
Name Sponsor Year (From - to) Position in Organization
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Scholarship Received (attach evidence if any.Write NONE if you don't have any)*
Name Sponsor Year (From - to) Description
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Academic/Non-Academic Achievements or Prizes (attach evidence if any. Write NONE if you don't have any)*
Achievement Place (city) Year Description
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If you have travelled or lived abroad, indicate place, purpose, time and other necessary information (if you have never been abroad, please write NONE)*
Name of Country Purpose Date (from-to) Funded by Description
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LANGUAGE SKILLS: (Rate yourself Excellent, Good, Fair or Poor. Include all languages in which you have some competence)
Mother Tounge:*
Name of Language Reading (Excellent/Good/Fair/Poor) Writing
(Excellent/Good/Fair/Poor)
Speaking
(Excellent/Good/Fair/Poor)
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Please provide the name, address and telephone number of individual to be notified in case of emergency. In home country*
Name Address, telephone, email
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Personal Statement: Write a clear and detailed description of your reason why you would like to participate in this Leadership Camp Program; explain how IILC fits your previous education/training and your future objectives. This statement should not be a mere listing of facts and should include information about your background education, practical experience, special interests, and your purpose in applying to learn about Leadership, Indonesian culture and Qori'. You may also choose to describe any significant influences on your personal and educational development. THIS STATEMENT IS AN IMPORTANT PART OF YOUR APPLICATION.*
What are your long term career aspirations? What skills do you need to achieve these Objectives?*
CERTIFICATION AND RELEASE AUTHORIZATION*
I certified that the information set forth in this application (include attachments) is true, complete and accurate. I authorize the release of any information necessary to confirm and / or verify this application.
INTERNATIONAL LEADERSHIP CAMP 2019
TERM OF AWARD AND SPECIAL INSTRUCTION
You have to read these Terms of Award and Special Instructions carefully, please sign where indicated and return to the Indonesia International Leadership Camp (IILC) of Al Azhar Youth Leader Institute.

1.      PURPOSE
By receiving this award, you have been given the opportunity to improve your Leadership skill and to learn more about Indonesia (Language and Culture) by studying at Al Azhar Youth Leader Institute from 10/12/2019 until 19/12/2019. In addition you will learn about the Indonesian language, pencak silat (culture) and Qira’ah (Art Reading Qur’an) in order to enhance your understanding of Indonesian society    and cultures. Also, you will be given an opportunity to develop your critical thinking and interpersonal skills. This program will be both academically rigorous and intellectually challenging. Accordingly, the following terms and special instructions of this grant are outlined below.

2.      FINANCIAL TERMS
The following financial provisions have been provided to you by the Al Azhar Youth Leader Institute :
a)      Living Expenses & Arrangements: Room and board accommodations for this program will be funded directly by the Al Azhar Youth Leader Institute (AYLI) on your behalf. All housing and meal arrangements have been arranged and you will receive additional information upon arrival.
b)      Study Fees: Your study fees and any required learning fees for this program have been provided by AYLI.
c)      Health Benefit Plan: The AYLI provides health and accident benefits. This coverage is not all-purpose health insurance; it is subject to specific limitations and is provided only through your authorized period of IILC sponsorship. You will receive additional information upon arrival.

3.      DURATION OF STAY
You will be required to complete your grant in the program at Al Azhar’s Mosque in Jakarta. No extensions of sponsorship period will be permitted. Should an emergency necessitate early departure, prior approval must be obtained through AYLI will not be liable for any claim(s) resulting from your failure to enter upon or to complete the program.

4.      IILC FOLLOW-ON RESPOSIBILITIES AND ACTIVITIES : As a requirement of accepting this award you will be required to act as an participant of IILC by learning about Leadership skill, Qira’ah (art of reading Qur’an), Communication skills, Managerial skills, Indonesian Language, Pencak Silat, Indonesian Islamic History and etc. During this period you will get the experiences of studying and living in Indonesia. You will recieve guidelines and instruction for these activities at a later date.

5. IILC TRAVEL POLICY
You are not permitted to travel within or outside Indonesia during your period of sponsorship. NOTE: Various intensive program activities have been pre-approved and arranged

6. PROGRAM SPECIFIC POLICIES
The participant must obey all of the rules :
1.      Follow all of the programs and obey to the time schadule which has been arranged by the commitee.
2.      Do not do any crimes, smoke, use any drugs (except the prescription from a doctor)
3.      The candidates of participant must confirm their arrival (date of flight including the number of the flight) and send them to: rifkymhdd@gmail.com

7.      RIGHT AND RESPONSIBILITIES
The participants have the several things to be considered :
1.      Participants have to obey all of the rules that have been made by commitee.
2.      Participants have to join all of the entire schedule of the Indonesia International Leadership Camp (IILC) of Al Azhar Youth Leader Institute that have been arranged by the committee.
3.      Every complain can be sent to all the members of Organizing Comittee of IILC

8.      RULES AFTER JOINING PROGRAM
All the participants will became members of AYLI after the event of Indonesia International Leadership Camp and have the responsibility to develop the Leadership Potential of all the youth in every participant’s country

9.      REVOCATION, TERMINATION AND SUSPENSION OF AWARD
If the participants are not able to continue the program of Indonesia International Leadership camp then by all means participants must leave Indonesia maximum 1 day after the statement to stop continuing the program.

10. ACCEPTANCE OF TERMS OF AWARD AND SPECIAL INSTRUCTION : Sign below and return a copy of these Terms of Award and Special Instruction to AYLI to indicate that you understand, accept, and will comply with all provisions stated above. By signing these Terms of Award and Special Responsibilities you are agreeing to the policies of AYLI outlinedd above. NOTE : The Terms and conditions of the award are not negotiable upon arrival.
Signature
Clear

	Year of enterd	Year of graduated	Name of school
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	Name	Institution	Year (from - to)	Result
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	Activity	Institution/Organization	Year (From - to)
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	Name	Sponsor	Year (From - to)	Position in Organization
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PERMANENT MAILING ADDRESS