Apply for the Youth Cross Exchange Intake (Individuals Only)

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Human Rights Defenders Assessment Form for Participation/ Intake into The Youth Cross Exchange Programme

Apply Offline (Click the button to Download the Offline Application Form)

PART A

Applicant / Human Rights Defender

First Name *

Surname *

Other Names (nickname)

Address *

Date of Birth *

Month

Day

Year

Sex *

Female

Male

Nationality *

Country of Origin *

Country of residence (if currently out of your country of origin)

Details of organization (if different from the Human Rights Defender)

Contact Person

Name of Organisation

Country (District, Region)

Phone

Skype

Signal

PART B

Contact Information

Phone Number

WhatsApp Number / Signal

Email Address

Other

What is your preferred mode of Communication? *

Signal

Phone

PART C

Your Background Information

How long have you been engaged in Human rights work? Do you have an understanding of Human Rights? *

In reference to the UN Declaration on Fundamental Human Rights and Freedoms and in accordance with the national laws of your country, what are the key Human Rights issues you are involved in as a Human Rights defender? Describe the human rights work you are / have been involved in. *

Are you affiliated to any organization? *

Yes

If YES give the name of the organization and reasons for your affiliation and the kind of human rights work your organization is involved in. *

If no describe how you carry out your work *

What are some of the achievements you have attained as a Human Rights Defender? *

PART D

Security Context

Describe the previous and or current security situation surrounding your work. For example, have you been arrested before, have you received any death threats, have you been a subject of blackmail in your community, country among others, if yes….please describe clearly stating the incident, when it happened, how it happened, where it happened and who could have done it and how you have been able to respond. *

What are some of the challenges you have been facing as a Human Rights Defender? *

Do you find Human Rights work a challenge, if YES why? *

Do you find it proper to share with us your photo? If yes, may you attach it Here?

Files must be less than 1 MB.
Allowed file types: gif jpg jpeg png.

PART E

Assistance

I. Have you been able to get any assistance? If yes, what kind of assistance (financial, legal, medical, others) *

II. If no, would you like any assistance in regard to your work and or security situation? If yes, what could that be? Please fill in the table below. *

ITEM	Unit Cost (in dollars)	Frequency	Total	Description
ITEM	Unit Cost (in dollars)	Frequency	Total	Description
ITEM	Unit Cost (in dollars)	Frequency	Total	Description
ITEM	Unit Cost (in dollars)	Frequency	Total	Description
ITEM	Unit Cost (in dollars)	Frequency	Total	Description
ITEM	Unit Cost (in dollars)	Frequency	Total	Description
ITEM	Unit Cost (in dollars)	Frequency	Total	Description
ITEM	Unit Cost (in dollars)	Frequency	Total	Description
ITEM	Unit Cost (in dollars)	Frequency	Total	Description

PART F

Please provide details of at least two referees who may provide more information about your work and could endorse you for this programme.

Referees

REFEREE NUMBER	NAME	EMAIL	PHONE	ORGANIZATION	SKYPE	SIGNAL
REFEREE NUMBER	NAME	EMAIL	PHONE	ORGANIZATION	SKYPE	SIGNAL
REFEREE NUMBER	NAME	EMAIL	PHONE	ORGANIZATION	SKYPE	SIGNAL

Leave this field blank

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Apply for the Youth Cross Exchange Intake (Individuals Only)

Human Rights Defenders Assessment Form for Participation/ Intake into The Youth Cross Exchange Programme

PART A

Applicant / Human Rights Defender

Details of organization (if different from the Human Rights Defender)

PART B

Contact Information

PART C

Your Background Information

PART D

Security Context

PART E

Assistance

PART F

Please provide details of at least two referees who may provide more information about your work and could endorse you for this programme.

Recent Annual Reports

Recent Publications

Apply for the Youth Cross Exchange Intake (Individuals Only)

Human Rights Defenders Assessment Form for Participation/ Intake into The Youth Cross Exchange Programme

PART A

Applicant / Human Rights Defender

Details of organization (if different from the Human Rights Defender)

PART B

Contact Information

PART C

Your Background Information

PART D

Security Context

PART E

Assistance

PART F

Please provide details of at least two referees who may provide more information about your work and could endorse you for this programme.

PART F

Consent

Recent Annual Reports

Recent Publications