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  • Who We Are
    • Mission and Vision
    • From the President
    • History
    • Board of Directors
    • Board of Advisors
    • Team
    • Partnerships
    • Funders
    • Annual Reports
  • What We Do
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    • Global Youth Programs
    • Professional Development
    • Social Entrepreneurs
  • Our Approach
  • Our Impact
    • Meet Our Alumni
    • In The News
  • Programs
    • Community Building & Social Cohesion
    • Emerging Young Leaders Award
    • Global Youth Village
    • LivingSidebySide® Programs
    • Professional Fellows Program
    • Saudi Young Leaders Exchange Program
    • TechGirls
    • Past Projects
  • Get Involved
    • Host an International Visitor
    • Donate
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Legacy International > Professional Fellows Questionnaire

Professional Fellows Questionnaire

The following questionnaire will help Legacy’s team prepare for your five week stay in the U.S. Your responses will be used for assuring your well-being and comfort during your visit.
Please use as much space as you need, and answer the questions with as much detail as possible. This information will be kept confidential. Please complete the questionnaire by Sunday October 9th. If you have questions, please contact: aaleavitt@legacyintl.org

Step 1 of 4

25%
  • Participant Background Information

  • (Your legal name as listed on your passport. This is how it will appear on such documents as a certificate of participation, airline ticket etc.):
  • If applicable, please enter the name or nickname you want to be called on this Program:
  • country code - city code- phone number
  • In case of emergency, whom should Legacy contact?
  • country code - city code- phone number
  • country code - city code- phone number
  • Alternate emergency contact, if person listed above is not reachable.
  • country code - city code- phone number
  • country code - city code- phone number
  • (For example: no shellfish, no dairy, halal, kosher, vegan, etc)
  • (For example: 1 pack a day, only at night after dinner, etc.)
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  • Health Questions

    All medical information is kept confidential and only shared with others on a “need to know” basis. You will be provided with medical insurance to cover the costs of medical care in the US, should the need arise. It will not cover the costs of routine medical care or treatment for any pre-existing medical or dental condition. (Details will be provided at a later date.)
  • (For example, allergic to pollen, shellfish, peanuts, dogs, cats, mold, medications)
  • (If you require epinephrine for treating severe allergic reactions, please note this and be sure to bring this with you.)
    AllergyTreatment 
    Add a new row Remove this row
  • (For example: hard of hearing, difficulty walking up stairs, difficulty standing for long periods, etc.)
    Add a new row Remove this row
  • (For example: diabetes, asthma, heart disease, recent fracture which may affect mobility, etc.)
    Add a new row Remove this row
  • NOTE: Please be sure to bring enough medication to last your entire U.S. stay.)
    Add a new row Remove this row
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  • Technology Use

  • If yes, we strongly recommend that you bring your laptop (or tablet)
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  • Program Assessment

    (Please note that your answers to this section will be kept confidential)
  • Check your top 3
  • (Please select all that apply)
  • Please rank the following areas of interest to you personally, from 1 being the most important to 10 being the least important to you
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • 12345678910
  • Please check all the roles that you currently play or have played before. (Please check one box in each role):
  • I have never done thisAttend meetingsHelped plan activitiesLead events or activitiesTrain othersHeld a leadership positionStarted a new group or organization
  • I have never done thisAttend meetingsHelped plan activitiesLead events or activitiesTrain othersHeld a leadership positionStarted a new group or organization
  • I have never done thisAttend meetingsHelped plan activitiesLead events or activitiesTrain othersHeld a leadership positionStarted a new group or organization
  • I have never done thisAttend meetingsHelped plan activitiesLead events or activitiesTrain othersHeld a leadership positionStarted a new group or organization
  • I have never done thisAttend meetingsHelped plan activitiesLead events or activitiesTrain othersHeld a leadership positionStarted a new group or organization
  • Below is a list of different skills and abilities a leader might have. Please rate yourself on the following characteristics. Please check one box in each row.
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • Please rate your current knowledge and skill in these areas. Please mark “X’ in one box of` each row.
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • PoorFairGoodExcellent
  • Please specify below
    PoorFairGoodExcellent
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