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: email@example.com Step 1 of 4 25% Participant Background Information1. Full Legal Name*(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.): Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last 2. Name/NicknameIf applicable, please enter the name or nickname you want to be called on this Program:3. Birthdate* 4. Your Mobile*country code - city code- phone numberIn case of emergency, whom should Legacy contact? 6. Contact's Name* First Last 7. Contact's Relationship to you*8. Contact's Home Phone*country code - city code- phone number9. Contact's Mobile*country code - city code- phone number10. Contact's Email* Alternate emergency contact, if person listed above is not reachable.12. Alternate Contact's Name* First Last 13. Alternate's Relationship to you*14. Alternate's Home Phone*country code - city code- phone number15. Alternate's Mobile*country code - city code- phone number16. Alternate's Email* 17. Legacy factors in time each day for people to observe prayers during business hours. We will also suggest local mosques where you can attend Jumah prayer each week. We recommend that you download an app on your cell phone to provide local prayer times and indicate the direction of the Qibla, as you will not find this information readily available in U.S. hotels and businesses. Is there anything further Legacy can do to support the practice of your faith?*18. List your dietary restrictions or preferences, if any. (Please state 'None' if not applicable in the answer box below)*(For example: no shellfish, no dairy, halal, kosher, vegan, etc) 19. Do you smoke?*YesNoPlease estimate your daily use*(For example: 1 pack a day, only at night after dinner, etc.) Save and Continue Later Health QuestionsAll 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.)20. Do you have any allergies?*YesNoPlease list your allergies (If none, please state 'None' in the answer box below)*(For example, allergic to pollen, shellfish, peanuts, dogs, cats, mold, medications)Please list any treatment for allergies you typically use. (If none, please state 'None' in the answer box below)*(If you require epinephrine for treating severe allergic reactions, please note this and be sure to bring this with you.)AllergyTreatment 21. Do you have any physical limitations we should be aware of? Please list any. (If none, please state 'None' in the answer box below)*(For example: hard of hearing, difficulty walking up stairs, difficulty standing for long periods, etc.) 22. Do you have any on-going (chronic) or current medical conditions? Please list and elaborate how you are currently managing this condition. (If none, please state 'None' in the answer box below)*(For example: diabetes, asthma, heart disease, recent fracture which may affect mobility, etc.) 23. Have you been hospitalized in the past three years?*YesNoPlease describe reasons and actions taken.*24. Please list any medications you take on a regular basis, including dosage. (If none, please state 'None' in the answer box below)*NOTE: Please be sure to bring enough medication to last your entire U.S. stay.) Save and Continue Later Technology Use25. What social networking sites do you use?* Facebook Twitter Google+ Instagram WhatsApp YouTube Skype Other Twitter Username*Google+ Username*Instagram Username*YouTube Username*WhatsApp Username*Skype Username*Other Username*26. Do you have experience blogging?*YesNoFeel free to share the link to your blog with us. 27. Do you own a laptop?*If yes, we strongly recommend that you bring your laptop (or tablet)YesNo Save and Continue Later Program Assessment(Please note that your answers to this section will be kept confidential)Please identify your three most important reasons for participating.*Check your top 3 To develop my capacity and become a better leader and agent of change To develop a support network among other fellows and share knowledge, skills and resources To increase my understanding of United States and organizations there addressing the issue I am passionate about To receive support in developing a project to help improve my community To represent my country abroad and share my culture with others To take my existing project and develop a more in-depth strategic plan Other Please specify:*In which areas are you looking to develop yourself?*(Please select all that apply) Leadership Program design and management Advocacy and public policy reform Social media and digital storytelling Fundraising Networking Entrepreneurship models Dialogue skills, conference organizing skills Promotion of inter-religious freedom and pluralism; protecting minorities Citizen engagement tools Youth programming skills – teamwork, leadership development, etc. Other Please specify:*Please rank the following areas of interest to you personally, from 1 being the most important to 10 being the least important to youChildren’s services*12345678910Healthcare & health education*12345678910Education*12345678910Environmental concerns*12345678910Employment and local development*12345678910Human rights*12345678910Respect for diversity/Inter-ethnic/Inter-religious relations*12345678910Refugee and migration issues*12345678910Poverty issues / charity to the poor*12345678910Women’s concerns and needs*12345678910Effective programs for at-risk youths*12345678910Citizen engagement tools*12345678910Youth programming skills – teamwork, leadership development, etc.*12345678910Other (please specify below)*12345678910OtherPlease check all the roles that you currently play or have played before. (Please check one box in each role):Community Service*I have never done thisAttend meetingsHelped plan activitiesLead events or activitiesTrain othersHeld a leadership positionStarted a new group or organizationActivism on community issues*I have never done thisAttend meetingsHelped plan activitiesLead events or activitiesTrain othersHeld a leadership positionStarted a new group or organizationEnvironmental projects*I have never done thisAttend meetingsHelped plan activitiesLead events or activitiesTrain othersHeld a leadership positionStarted a new group or organizationReligious clubs and/or service groups*I have never done thisAttend meetingsHelped plan activitiesLead events or activitiesTrain othersHeld a leadership positionStarted a new group or organizationVolunteering with nonprofit & charitable organizations*I have never done thisAttend meetingsHelped plan activitiesLead events or activitiesTrain othersHeld a leadership positionStarted a new group or organizationBelow 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.Ability to work independently*PoorFairGoodExcellentWorking as part of a team*PoorFairGoodExcellentBeing Flexible*PoorFairGoodExcellentSpeaking in public*PoorFairGoodExcellentBuilding a coalition*PoorFairGoodExcellentSensitivity to others’ needs & concerns*PoorFairGoodExcellentCreative problem solving*PoorFairGoodExcellentPlanning for the future*PoorFairGoodExcellentManaging your time*PoorFairGoodExcellentManaging your money*PoorFairGoodExcellentDiscussing your beliefs & values*PoorFairGoodExcellentSuccess with making changes in your community/school*PoorFairGoodExcellentPlease rate your current knowledge and skill in these areas. Please mark “X’ in one box of` each row.How to plan projects*PoorFairGoodExcellentIdentifying & understanding problems in your community*PoorFairGoodExcellentHow to organize a team*PoorFairGoodExcellentHow to work in a team*PoorFairGoodExcellentDelegating responsibility to others*PoorFairGoodExcellentResearching needs or problems you have identified & evaluating alternative solutions*PoorFairGoodExcellentDeveloping a proposed new policy or action plan to solve a problem*PoorFairGoodExcellentOtherPlease specify belowPoorFairGoodExcellentOtherThank you for completing this survey! If you have additional comments you would like to make, please do so here. We value your thoughts.CAPTCHA Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.