The Compassionate Listening Project

MidEast Citizen Diplomacy
The Compassionate Listening Project
P.O. Box 17, Indianola, WA 98342 USA
360/297-2280 (360) 297-6563 fax
staff@compassionatelistening.org www.compassionatelistening.org

Registration - Compassionate Listening Project

Please print & carefully fill out the following form, then mail with your deposit.

Trip you are applying for:
Name:
Address:
City:
State:
Zip:
Telephone - Day:
Telephone - Evening:
Email:
Fax:
Date of Birth:
Occupation:
Employer:
Interests/skills:
Ethnic Identity (optional):
Religious affiliation/practice:
Accomodations
I prefer a ___ single room ___ double room
I wish to share a room with:
I am a ___ smoker ___ non-smoker
Country of Citizenship:
Exact name on passport:
Passport number:
Date of Issue (day/mo/yr):
Date of Expiration:
In case of emergency please notify:
Relation:
Phone(s):
Address:
What draws you to the Compassionate Listening Project?
Do you have any special dietary needs, medical conditions, allergies or disabilites that may affect your participation in this trip?
Participants are expected to have good communication skills and a commitment to conflict resolution. What are your strengths in this area?
How did you learn about this delegation?
___ I have read and understand the cancellation policy listed on the website.
We will reserve your space on this trip when we have received your registration and trip deposit, mailed to TCLP (address above).
Deposit paid by __ check enclosed (payable to Compassionate Listening Project); __ Visa; __ Mastercard.
Amount _________ Card Number ______________________ Exp. Date __________
Print name as it appears on card ________________________ Signature ________________________
*please note that credit card payments are assessed a 3% surcharge.