Please acknowledge you have read the above notice and agree with it before filling in this form: Please acknowledge you have read the above notice and agree with it before filling in this form: I Agree

First Name

Family Name

First Name for Name Tag

Date of Birth (dd/mm/yy)

Sex SexMaleFemale

Marital Status Marital StatusSingleMarriedSeparatedDivorcedRemarried

Place of Birth

Nationality

Do you need a visa for France? Do you need a visa for France? Yes No

Your Email Address

Your full permanent postal address

Your telephone you will be traveling with

Organization for which you work

Volunteer mission Volunteer mission Yes No

Who will pay for your stay?

Email address for billing

Your title/role in organization

Country/Region in which you are serving

Total years/month on field

Length of stay on field this term

Reasons for coming home this time

Is this your first debriefing at Le Rucher? Is this your first debriefing at Le Rucher? Yes No

When were you here before?

Other than "someone recommended it", why do you need debriefing? Please be specific.

Preferred language for debriefing - 1st choice Preferred language for debriefing - 1st choiceEnglishFrenchDutchGermanSwiss German

Preferred language for debriefing - 2nd choice Preferred language for debriefing - 2nd choiceSame as first choiceEnglishFrenchDutchGermanSwiss German

Debriefing Dates Preferred - 1st choice

Debriefing Dates Preferred - 2nd choice

Debriefing Dates Preferred - 3rd choice

Do you have health insurance that is valid in France? Do you have health insurance that is valid in France? Yes No

Are you taking any prescribed medications? Are you taking any prescribed medications? Yes No

Please Explain

Are you under the care of a professional psychologist or psychiatrist? Are you under the care of a professional psychologist or psychiatrist? Yes No

Please Explain

Have you been professionally diagnosed with: Have you been professionally diagnosed with:NoneDiabetesCeliac DiseaseSevere Lactose IntoleranceNut allergies

Contact in case of emergency

Their email address

Their telephone