"The Struggle for Health - IPHU Savar 2018"
Hard copy application form: only use this form if you are unable to use the online application form

The Struggle for Health - IPHU Savar 2018 will be held from Tuesday 6 November to Tuesday 13 November 2018, in the lead up to PHA4 - the Fourth People's Health Assembly. (Go to https://phmovement.org/peoples-health-assembly-dhaka/ for more information about PHA4.)

The announcement of the IPHU can be viewed or downloaded here: https://iphu.org/en/announcement/iphu-savar2018.

This IPHU will include two streams, one on Medicines and one on Gender, as well as several common days. See draft course plan, including the common days and the separate streams here: https://iphu.org/sites/default/files/DraftCoursePlanWithTopics_180731_0.pdf. This is a notional framework. It is currently under development. Watch this space!

This application form is only for those who are unable to access the online application form at https://iphu.org/en/savar2018/application.
(If you are unable to apply online, fill in this form and return it by email to iphu@phmovement.org. Please do not convert the form into PDF or into an image format).

Deadline for receiving applications: 14 September 2018

Acceptances and travel scholarships will be announced on 25 September.

Please go through the questions and requirements of the application form below before you start filling in the form.

Fields marked with * are mandatory.

Personal information

*Personal name: Click here to enter text.

*Family name: Click here to enter text.

*Gender:

Female:	☐

Male:	☐

Other:	☐

*Date of birth: Click here to enter a date. (dd/mm/yyyy)

Place of origin

*Country:	Click here to enter text.

*City:	Click here to enter text.

Place of residence

*Country:	Click here to enter text.

*City:	Click here to enter text.

Contact information

*Email address:	Click here to enter text.Indicate the email address on which you wish to receive all correspondences concerning the course.

Alternate emails:	Click here to enter text. (If you wish to provide more email addresses, please type one address per line.)

Skype ID:	Click here to enter text.

Phone numbers

Please provide at least one reliable telephone number. - Example: + (Country code) (City code) (Phone number)

Mobile:	Click here to enter text.

Home:	Click here to enter text.

Office:	Click here to enter text.

Fax:	Click here to enter text.

Post:	Click here to enter text.

Professional information

Title/affiliation/profession:	Click here to enter text.

Institution:	Click here to enter text.

Country:	Click here to enter text.

City:	Click here to enter text.

Institution email	Click here to enter text.

Institution website:	Click here to enter text.

Activism

*Choice of stream:	Click here to enter text.(Please specify which specialist stream you are applying for: Medicines or Gender).

Previous and current activism:	Click here to enter text. Please indicate if you are involved in People's Health Movement (PHM) in your country; and if so in what ways. If you have other involvements in health activism beyond PHM please describe. If you have activist involvements in relation to the specialist stream for which you are applying, please indicate here.

Why now and what later:	Click here to enter text. Why do you want to participate in this course, and what do you hope to be better able to do afterwards? Explain why you are applying for this stream, as well as the course, and what you hope to be able to do better afterwards?

Areas of interest:	Click here to enter text. Please list your areas of particular interest relating to health, both professional and activist/personal

Educational background:	Click here to enter text. Please describe your educational background

Current occupation:	Click here to enter text. Please describe your current occupation

Previous occupations:	Click here to enter text. Please describe your previous occupations (if applicable)

Referee:	Click here to enter text. Please list contact details (email, phone) for a reference who can speak about your health activism

Language skills

*Mother tongue:	Click here to enter text.

More languages

Please indicate all languages in which you have some competence and rate yourself excellent, good, fair, or poor.

Language 1:	Click here to enter text.

Language 2:	Click here to enter text.

Language 3:	Click here to enter text.

Please rate your language skills

Excellent	Good	Fair	Poor
Language (1)	☐	☐	☐	☐
Language (2)	☐	☐	☐	☐
Language (3)	☐	☐	☐	☐

Application for scholarship assistance

PHM-IPHU is committed to reducing the financial barriers to attending IPHU. A limited number of scholarships for travel and/or accommodation will be available for qualified applicants. It is expected that scholarship applicants will have committed to participating in PHA4 as well as the IPHU. Priority will be given to qualified applicants from Bangladesh (as the host country) and from South Asia and South East Asia. Travel scholarships for qualified Bangladeshi participants from outside Dhaka is subjected to a fixed rate, estimated based on the average cost of travel by bus or train. In case of travel scholarships for qualified international participants requiring air travel, flight tickets will be booked by the PHM Global Secretariat upon a written confirmation by the participant of the itinerary provided. Most of flight tickets will be non-refundable; accordingly, participants will be asked to pay back the cost of their tickets if they did not show up. This policy is only to ensure that we are using our limited resources efficiently. Registration fees are mandatory for all participants. Activists’ accommodation will be reserved in shared, basic facilities PHM-IPHU scholarships do not cover visa fees, airport tax & travel insurance (if applicable), personal living expenses, per diems, or local transportation in the home country. Applicants should seek such support from sponsors in their own countries in the first instance.

Fees

Registration

Registration, which covers all training materials, lunch and coffee breaks during the training days is mandatory.

USD50 (or equivalent) for low and lower middle income countries

USD100 (or equivalent) for upper middle and high income countries

Tuition

Tuition costs are supported by the PHM for all participants. There is no charge.

Accommodation

Subsidized accommodation at Gonoshasthaya Kendra (basic, shared facilities including bed, breakfast and dinner) will be reserved from the evening of Monday 5 November to the morning of 19th November (following conclusion of PHA4), subject to confirmation.

*Scholarships

Yes	No
I apply for scholarship to cover my travel costs	☐	☐

Circumstances:	Click here to enter text. Outline your circumstances (in case of your selecting ‘yes’)

Travel information

For applicants from outside Bangladesh. If you are applying for a scholarship to cover your travel costs, please indicate the country and city of the nearest international airport you will be departing from.

Country:	Click here to enter text.

City & airport:	Click here to enter text. Indicate the city and the airport from which you would travel.

Passport information

Please complete this section if you need a visa and wish to receive a formal Invitation Letter in case of acceptance. International applicants need to have a valid passport for at least six months from the date of travel. Please ensure to provide the correct information.

Name (in passport):	Click here to enter text.

Place of birth:	Click here to enter text. Please indicate both City and Country.

Nationality:	Click here to enter text.

Passport number:	Click here to enter text.

Place of issue:	Click here to enter text.

Date of issue:	Click here to enter text.

Date of expiry:	Click here to enter text.

Visa

Do you need a visa to Bangladesh?

Yes:	☐

No:	☐

In case of acceptance, a copy of the invitation letter will be sent to the embassy/consulate of Bangladesh, if needed, to issue the visa.

Do you have an embassy/consulate for Bangladesh in your country?

Yes:	☐

No:	☐

You may find relevant information at http://visitbangladesh.gov.bd/travel-essentials/visa-service/.

If yes, please provide the contacts of the visa section:

Fax number/s:	Click here to enter text.

Example: + (Country code) (City code) (Phone number) - You can add several numbers separated by commas.

Email address:	Click here to enter text.

Phone number/s:	Click here to enter text.

Example: + (Country code) (City code) (Phone number) - You can add several numbers separated by commas.

If no,

Please find out how the visa can be issued in your country and provide us with the details including: fax number(s), email address and phone number(s) of the visa section.

Details:	Click here to enter text.

Special needs

Do you have special dietary requirements? If yes, please specify

Special dietary needs:	Click here to enter text.

Do you have a disability that might need special requirements? If yes, please specify

Special requirements:	Click here to enter text.

Awareness

How did you know about the PHM-IPHU course?

PHM website:	☐

PHM Exchange:	☐

Friend or colleague:	☐

Mailing list:	☐

If other, please specifyClick here to enter text.

The People's Charter for Health is the founding document of the People’s Health Movement (PHM). We ask that all applicants to the International People's Health University read the People's Charter for Health. (https://phmovement.org/the-peoples-charter-for-health/)

The Preamble from the Charter reads:

Health is a social, economic and political issue, and above all a fundamental human right. Inequity, poverty, exploitation, violence and injustice are at the root of ill health and the deaths of poor and marginalized people. Health for all means that powerful interests have to be challenged, that corporate-led globalization has to be opposed, and that political and economic priorities have to be drastically changed.

*Certify *

☐ I certify that all of the information contained in this application is true. I have read the People’s Charter for Health and I confirm that I am committed to the broad directions, analysis and strategies outlined in the Charter.