Name

First Name

Last Name

Phone Number where we can best reach you at

Please share with us a 5-6 sentence professional summary that we could use to have shared publicly on our website.

Emergency Contact Person

Name and Relationship to You

Emergency Contact Person's Number

Emergency Contact's Email

Which city & country do you plan on traveling to and from Vieques?

Dietary Considerations

Vegetarian? Allergies? Reglious observations?

Do you have any health conditions that we should be aware about?

If you don't have any conditions, just say "not applicable."

Do you have any religious customs/observations that we should be aware of?

Are there any activities or rituals that help keep you balanced?

e.g.: yoga, meditation, fencing, wordcross puzzles, etc

What is your sleeping habit?

Do you prefer to go to bed early and rise later? Or do you tend to go to bed later at night? Can you sleep through a lot of noise and light? Or are you sensitive to noise and light?

List 2 - 3 top topics / skills you want to learn during GSIH

What are 2 - 3 of your biggest needs personally and/ or for your organization?

List 2 - 3 habits you want to improve in your life to become a more effective leader.

Visa and related documentation

Do you have all the visa related documentation prepared and ready for your travel to Puerto Rico?

I am a US citizen, and have proper travel documentation

I am not a US citizen, but have proper visa/travel documentation to enter Puerto Rico

I am not a US citizen, and do not currently have the visa or travel documentation to enable travel to Puerto Rico

I understand that by completing this form, I am accepting a spot in theo 2014 Global Social Impact House.

Vieques, here I come!

Do you have any additional information you would like us to know about you?

Let us know!

Fellow Information

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