Mental Health Exchange Programme - Netherlands, 2nd wave

First name (in Latin Alphabet) *

Please indicate your name as indicated in your passport

Last name (in Latin Alphabet) *

Please indicate your last name as indicated in your passport

Date of Birth *

Nationality *

Country of Residence *

Please note that we can only accept participants residing in one of the 27 EU Member States, Norway or Iceland (regardless of their nationality). If you don't reside in one of those countries, please refrain from applying.

Other *

Email *

Please confirm by entering your Email address twice.

Confirm the previous field *

Mobile Phone *

My level of English is equal or major of B/intermediate *

Exchange visits will be performed in English. This is an intermediate-level qualification for those who master the basics of English and have practical language skills for everyday use. Please assess your English proficiency using the Europass Self-Assessment Grid based on the CEFR.
Link to the Europass Self-Assessment Tool: https://europass.europa.eu/en/common-european-framework-reference-language-skills

Do you work for / cooperate with one of the other organisations that hosts our Exchange Programme? *

Which hub are you affiliated with? *

What is your role at the affiliated hub? *

Gender Identity *

Please select your professional profile: *

Years of Experience *

Institution/Organisation *

Years within the Institution/Organisation *

Official Job Title *

Please give your official Job Title

Position within the Institution/Organization *

Please describe your responsibilities and tasks in your daily job in English

Please share a specific personal experience or realisation that inspired you to apply for this exchange programme, which focuses on learning about another country's mental health practices and community-based care system. How has this experience shaped your view on the significance of community-based mental health initiatives? *

Please write in English not more than 250 words

In the future, how do you plan to integrate the knowledge gained from studying another country's practices and systems into your career goals? What impact do you aim to achieve in your community or field as a result of this exchange experience? *

Please write in English not more than 250 words

I confirm my participation in the Mental Health Exchange Programme. *

I agree to the terms regarding programme costs, cancellations, and the accuracy of personal information provided. *

Are you particularly interested in one of the areas of the programme? Please indicate (Please note that this does not guarantee any specific arrangements from the organisers.):

Leave blank if answer is "No"

How do you prefer to travel to the destination? *

Please be aware that flights are booked directly by us. All other modes of transport will be booked by you and reimbursed after completion of the Exchange Programme.

Other *

Please choose your starting airport (in your home country) *

Other *

Gender *

Please indicate your gender as reported in your passport in order to book your flight:

I agree that my data (name, surname, mobile, email, DoB) will be shared with the travel agency for flight booking. *

If you don't agree, please choose a different mode of transport.

I have read and understood the terms and conditions for reimbursement of travel and meal expenses. *

Do you have any medical conditions or pathologies that we should be aware of? If yes, please provide details.

Please also provide details on arrangements that should be made by our side.

Do you have any dietary restrictions or special requirements? *

Other *

Please specify your allergies: *

Do you need any special arrangements due to disabilities or special needs? Please specify.

Will you require daycare services for your child(ren) during the Exchange Visit?

Your Options: Option 1: A person of trust comes along and takes care of the child. In this case, we pay flights & accommodation for your family members (no per diems). Option 2: You come alone with your child. In this case please specify your needs so that we can arrange it. Your child's flight & accommodation is taken care of. *

Please choose between these two Options

Please specify: What kind of Childcare do you need? *

Please provide the name the person coming along *

Please provide the name of your child(ren) *

Please provide the date of birth of your child(ren) *

Full Name *

Email Address *

Confirm the previous field *

Phone Number *

Relationship *

Do you have your EHIC? *

Please check if you already have a European Health Insurance Card (EHIC). You can find this information on the back of your health insurance card. If you do not have one, please request it from your health insurance provider. All EU participants, as well as participants from Norway and Iceland, are covered through their EHIC for any medical needs. If you do not have an EHIC, please request it from your country of residence. If you are not covered, inform your event manager, and individual arrangements will be made.

Other *

Do you need an official invitation letter for your organization to authorize the mission? *

Name of Organisation *

Name of Superior (if needed)

Street *

Zip Code *

City, Country *

Bank Account Holder (Name) *

Name of Bank *

IBAN *

Street & Number *

Zip Code *

City *

Country *

Nationality *

Other *

How did you hear about this event? *

Other *

I have read and understood the Consent for Data Protection Notice for the Exchange Visits. *

Consent to the use of data*

List of participants: I hereby agree that my personal data – name and surname: professional profile, organisation, email and mobile – will be named and published in the list of participants of the programme.

I hereby agree to be part of pictures taken during the visit for reporting and communication purposes. *

I understood *