16^th World Conference on Tobacco or Health in Abu Dhabi- Youth Pre-conference Registration & Scholarship Application Form

16^th World Conference on Tobacco or Health in Abu Dhabi- Youth Pre-conference Registration & Scholarship Application Form

Admission to the Youth Pre-Conference is based on the following eligibility criteria:

·         Aged between 18-30 years

·         Affiliated to a tobacco control organisation/ Health organisation/Development Organisation

·         Work or live in a low- or middle-income country (see list of eligible countries on website – www.wctoh.org)

·         Have no affiliations to the tobacco industry

·         Experience/knowledge in advocacy campaign on tobacco control/other health issues

·         Played leadership role in the past at school/University/community setting/other

·         Reasonable knowledge of English

·         Should be in a position to implement learnt strategies on returning back to their country

Please complete all the fields and submit your form with the necessary attachments to youth@wctoh.org by the deadline of Friday 31 October 2014. No late applications will be accepted.

PERSONAL PROFILE
Title:	c Prof               c A/Prof             c Dr                 c Mr               c Mrs               c Ms               c Other:
Given name (as on passport):
Family name (as on passport):
Gender:   c   Male         c  Female
Birth date:			(DD/MM/YYYY):					Nationality:
Fluency in English Written Spoken			c Excellent   c Average     c Can manage c Excellent   c Average     c Can manage c Excellent   c Average     c Can manage
Organisation Please include an official recommendation letter from the organisation you are affiliated with. The letter should be from your supervisor or someone who is familiar with your tobacco control work. It should mention your contribution to tobacco control/other health issues and your potential for future work in tobacco control.
Type of organisation: Please select only one of the following options						c    Hospital c    Research Institute c    Government Agency c    Non-government Agency                        c    Voluntary Welfare Organisation c    Professional Society/Association c    University c    School c    Private Company c    Other:
Type of work:						Designation/Position:
Email:

BUSINESS ADDRESS
Street:
Postal Code:		City:
State:		Country:

REFERENCES (Optional) Please provide details of the person outside your organisation who is familiar with your tobacco control work/efforts.
Title:
Given name:
Family name:
Gender:	c    Male                 c    Female
Organisation/ Company:
Designation/Position:
Email:

ADDITIONAL DETAILS
Dietary preference:	c    Vegetarian                   c    Halal                  c    Other…. c    No Preference
Have you attended previous WCTOHs?	c   Yes                  c No
How did you know/hear about 16th WCTOH?	c   Word-of-mouth c   Email (Direct/Forwarded) c   Posters c   Other Conferences c   Other Websites c   Press Release c   Journal Advertisements

DISCLOSURE OF INTEREST
Do you and your spouse have any actual, potential personal financial and/or interests with any TOBACCO-RELATED COMMERCIAL ENTITY within the past 5 years?	c  Yes               c No
If yes, please provide details on the nature of interest. Check all actual, potential personal financial or other interests within the past 3 years.	Describe the interest (e.g. identity of tobacco-related commercial entity, nature of interest or relationship etc.)
c  Employment / directorship position
c  Intellectual property rights holder
c  Consultant / advisory role
c  Honoraria, gifts or favours received from tobacco-related commercial entities or their agents
c  Research funding / contracted research
c  Ownership interests (stocks, stock options, partnerships or other ownership interest)
c  Expert testimony
c  Other interests (including anything that may affect your objectivity or independence in relation to your WCTOH participation)

DECLARATION
I declare that the information given is correct and complete at the point of my registration. The Organising Committee reserves the right to reject my registration if the information is found to be incorrect.	Signature

SCHOLARSHIP APPLICATION

I would like to apply for a scholarship I need support for: All applicants MUST attach a write-up detailing your tobacco control efforts. This can be in essay-format and include the following components (maximum of 500 words). Please submit using word or pdf. -          Your work related to tobacco awareness and Advocacy in the last 2 years -          International experience in tobacco control activities -          Your organization’s recent work in tobacco control -          Why are you interested in participating in this youth conference? List 3 main expectations -          What are your current goals in life and how do they relate to the goals of the youth conference? -          How do you plan to share your experiences after attending the youth conference

c  Yes                 c  No c  Travel             c Accommodation       c Per diem

Composition of Scholarship

The conference organisers will arrange and make payment for the following:

·         6 nights’ accommodation (twin sharing) for the duration of the Youth Pre-conference and Main Conference

·         Registration fee for the Youth Pre-conference and Main Conference

·         Travel support (partial or full) to attend the Youth and Main Conference

All applications will be evaluated by the Youth Conference Scholarship Committee. Please note that Youth Pre-conference scholars may be expected to share their tobacco control efforts at either the Youth Pre-conference or the Main Conference.

Your application and supporting documentation must be submitted to youth@wctoh.org no later than Friday 31^st October 2014.