WILD 2016 APPLICATION FORM
APPLICATION DEADLINE: MONDAY, FEBRUARY 1, 2016
Applications in English are strongly preferred, and will NOT be judged on English spelling, grammar
or vocabulary.
If you prefer to complete your application online, visit: WILD 2016 Online Application Form
SECTION 1: APPLICANT INFORMATION
Family Name:
Given Name:
Birth Date: Month:
Day:
Year:
E-mail Address 1:
E-mail Address 2:
Skype name:
Home Address:
City/Village:
Province/State:
Country:
Postal Code:
Home Phone/TTY: (
Mobile Phone/Text: (
)(
)(
)
)
Note: Please put your phone numbers in the format of: (Country code), (City code), Local number
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Do you have a current passport?
NO
YES
Country of Passport
Passport Expiration Date: Month:
Day:
Year:
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Do you have a current U.S. Visa?
NO
YES
Type of U.S. Visa:
Visa Expiration Date: Month:
Day:
Year:
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What is your primary language used to communicate with others at home and/or work?
What is your English Language level?
None
Beginning
Slow
Fast
Fluent
What is your American Sign Language (ASL) level?
None
Beginning
Slow
Fast
Fluent
What is your Spanish language level?
None
Beginning
Slow
Fast
Fluent
What other Languages do you speak or sign?
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Please list two people we could contact if we are not able to reach you:
1) Personal Acquaintance (i.e. friend, family member)
Name:
Relationship to you:
Email address:
Home Phone/TTY: (
Mobile Phone/Text: (
)(
)(
)
)
Note: Please put your phone numbers in the format of: (Country code), (City code), Local number
2) Main contact person at work
Name:
Position/Title:
Email address:
Work Phone/TTY: (
)(
Mobile Phone/Text: (
)
)(
)
Note: Please put your phone numbers in the format of: (Country code), (City code), Local number
SECTION 2: DISABILITY INFORMATION
MIUSA’s 8th International Women’s Institute on Leadership and Disability (WILD) program is
designed to meet the leadership needs of women with disabilities. MIUSA will select qualified
women of diverse geographic regions, age, ethnic background and type of disabilities. MIUSA will
make appropriate arrangements for each qualified applicant, to ensure that each delegate with a
disability can participate as fully and equally as possible. To help us meet this goal, please
complete the following:
Do you have a disability?
NO
YES
If yes, what type of disability? Please mark all that apply.
Blind/Low Vision
Deaf/Hard of Hearing
Physical disability, and may use crutches, calipers, wheelchairs and/or prosthetics
Health-related
Psychosocial
Learning
Intellectual
Speech/communications
Autism spectrum
Other: ________________
Please describe your disability:
SECTION 3: PROFESSIONAL INFORMATION
1. What type of organization would you represent at WILD? Please mark all that apply.
Disabled People’s Organization
Academic Institute (school or university)
Government Agency
Women with Disabilities Organization / Wing / Group / Committee
Private Sector
International or community development organization
Other (Please specify)
2. What is the name of the organization?
3. What is the organization’s website, if applicable?
4. What is the purpose, mission or goal of the organization? (Limit 100 words)
5. What is your position / job title?
6. How long have you been in this position?
7. What are your daily tasks and responsibilities?
8. What is your highest level of education completed (i.e. elementary, secondary school,
private school, technical school, university)?
9. Areas of professional focus:
Please review the list of focus areas below and select your top three areas of interest/focus.
For each area of interest you selected, please briefly describe your experience. For example: I
have conducted projects focused on this issue; I have facilitated trainings on this issue; I have
attended trainings or conferences on the issue; I have partnerships with organizations working
on this issue, etc.
Choose ONLY THREE and describe your experience:
Gender-based violence prevention and response
Women’s health/ Reproductive health
HIV&AIDS prevention/treatment
Economic empowerment
Education
Legislation/ policy
Political participation/ Elections
Emergency preparedness and response
Youth leadership
Sports and recreation
Arts
Media (Journalism, TV, Radio, Social Media)
Transportation
10. Education and future career (employment or volunteer) goals:
1) What is your dream or goal to further your education, if applicable?
2) What is your dream or goal for your own future career and/or employment? For example,
what type of job, what position, and what employer?
SECTION 4: ESSAY QUESTIONS
Leadership experience(s)
1. In one paragraph, please tell us about the most successful project, program or initiative you
have worked on for the rights of women and girls with disabilities. What were the activities?
What were your contributions and how did the project, program or initiative impact the lives
of women and/or girls with disabilities?
2. What additional leadership experiences have you had in your community (i.e. home, school,
work), country, region and/or internationally? For example, what organizations, activities,
events or programs have you been involved in, what was your role, and what were your main
contributions?
3. What experiences, resources, skills or strategies could you share with other women leaders
with disabilities at WILD?
4. Why is it important for you to participate in the WILD program? What would you seek to
learn at WILD to make you a stronger and more effective leader? What experiences,
information, resources, or ideas would you be looking for?
5. Please describe your experience, personal or professional, with women with different types
of disabilities (physical, visual/Blind, hearing/Deaf, intellectual, psychosocial, health, etc.).
Inclusive Strategies for Empowering Women and Girls with Disabilities
In every community and region, there are programs that address critical issues for the
advancement and empowerment of women and girls in areas such as employment, education,
health care, political participation, youth leadership, violence prevention, child protection, etc.
Many of these programs are conducted by international development organizations, or led by or in
partnership with government agencies, faith-based organizations, local non-profit organizations,
and/or businesses.
Women and girls with disabilities are often overtly excluded from these programs, or do not
participate due to discrimination, lack of accommodations such as sign language interpreters, lack
of accessible transportation, inaccessible facilities and materials, etc. Women with disabilities
often do not have access to information about the services, and may not believe that they can, or
know that they have the right to participate in these programs.
Please describe:
1. Your experience collaborating and/or working with international development organizations
in your community and/or country. Please tell us the name of the organization(s) and
describe your specific experience (i.e. partnership on a program, participation in a training,
attending a workshop, volunteering)?
2. What have YOU (yourself or with a group or organization) already done to increase the
participation of women and girls with disabilities in existing community development
programs for women and/or girls (not disability focused)?
3. Imagine that there is a program in your community run by a U.S.-based international
development organization that provides literacy training to women and girls. What are three
specific actions you would take to ensure that women and girls with disabilities
participate in this program? Please be creative, and as specific as possible.
1)
2)
3)
One-day leadership and empowerment training for women with disabilities in your
community
All WILD delegates will be required to design and implement their own leadership training for
women with disabilities when they return to their countries, based on the WILD model. MIUSA will
offer a small, modest seed grant to all WILD delegates to cover costs for this activity. Please
answer the following questions as if you were preparing for a one-day leadership and
empowerment training for women with disabilities in your community.
1. What topics and activities would you include in your training?
2. Partner organizations: Based on the issue(s) you selected, please list three potential
organizations that you would propose to partner with to implement your WILD training.
For each organization you list, describe how they could be involved in your WILD training.
3. All WILD delegates will be required to obtain additional community support for your training.
What resources are available in your community to implement your training project? (i.e.
venue, in-kind support, resource people, technology support, volunteers, etc…) Please be
specific.
4. Please list five specific steps you would need to take to implement your training.
1)
2)
3)
4)
5)
5. Please describe how you would evaluate the training. How would you know whether the
training had been successful?
Additional information
1. How will you ensure that women and girls with disabilities in your community benefit from
your participation in the WILD 2016 program? Please be specific.
2. Please list:
a. Any previous experience with international exchange programs, trainings or
conferences (where, why and when)
b. Any previous travel to the USA (where, why and when)
3. Please tell us anything else we should know about why you should be considered for the
WILD 2016 program.
4. How did you learn about the WILD program?
5. Please indicate:
I have completed the application independently
I have completed the application with assistance from a professional
interpreter/translator
I have completed the application with assistance from a colleague, friend or family
member
APPLICATION DEADLINE: February 1, 2016
Please send word version of application by e-mail (preferred), or fax:
Mobility International USA (MIUSA)
2016 WILD Program
Email: womenleaders@miusa.org
Fax: +1-541-343-6812
2016 Women’s Institute on Leadership and Disability (WILD)
Recommendation Form #1
To be completed by the reference person. Please type or print clearly. All completed
recommendation forms must be submitted to MIUSA by February 1, 2016. If you prefer to complete
your recommendation form online, visit: 2016 WILD Online Recommendation Form
WILD Applicant Information
Please identify the person who is applying to be a participant in MIUSA’s 2016 International
Women’s Institute on Leadership and Disability (WILD).
Name of WILD 2016 applicant:
Applicant E-mail address(es):
Applicant Country:
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Name of person giving reference:
Work/Organization Affiliation:
Title/Position:
Email address(es):
Organization Website:
Tel/TTY: (
)(
Mobile/Text: (
)
)(
)
(Please put your phone numbers in the format of: Country code, City code, Local number)
1. Please briefly state the goals or mission of your organization (100 words or less).
2. What is your relationship to the applicant and how long have you known the applicant?
3. Why do you recommend this applicant for MIUSA’s WILD 2016 Program?
4. Please comment on how the applicant interacts with others in a group setting and in a fastpaced environment. How does the applicant handle being with a diverse group of individuals
who may have opposing religious, political, and/or cultural opinions and beliefs?
5. If selected, how would the applicant's participation in the 2016 WILD program help your
organization to increase the rights of women and/or girls with disabilities in your community?
I hereby certify that all information provided in this recommendation form is true and
accurate to the best of my knowledge.
Please submit the recommendation form online or send via e-mail (preferred) or fax:
Mobility International USA (MIUSA)
2016 WILD Program
Email: womenleaders@miusa.org
Fax: +1-541-343-6812
2016 Women’s Institute on Leadership and Disability (WILD)
Recommendation Form # 2
To be completed by the reference person. Please type or print clearly. All completed
recommendation forms must be submitted to MIUSA by February 1, 2016. If you prefer to complete
your recommendation form online, visit: 2016 WILD Online Recommendation Form
WILD Applicant Information
Please identify the person who is applying to be a participant in MIUSA’s 2016 International
Women’s Institute on Leadership and Disability (WILD).
Name of WILD 2016 applicant:
Applicant E-mail address(es):
Applicant Country:
=====================================================================================
Name of person giving reference:
Work/Organization Affiliation:
Title/Position:
Email address(es):
Organization Website:
Tel/TTY: (
)(
Mobile/Text: (
)
)(
)
(Please put your phone numbers in the format of: Country code, City code, Local number)
6. Please briefly state the goals or mission of your organization (100 words or less).
7. What is your relationship to the applicant and how long have you known the applicant?
8. Why do you recommend this applicant for MIUSA’s WILD 2016 Program?
9. Please comment on how the applicant interacts with others in a group setting and in a fastpaced environment. How does the applicant handle being with a diverse group of individuals
who may have opposing religious, political, and/or cultural opinions and beliefs?
10. If selected, how would the applicant's participation in the 2016 WILD program help your
organization to increase the rights of women and/or girls with disabilities in your community?
I hereby certify that all information provided in this recommendation form is true and
accurate to the best of my knowledge.
Please submit the recommendation form online or send via e-mail (preferred) or fax:
Mobility International USA (MIUSA)
2016 WILD Program
Email: womenleaders@miusa.org
Fax: +1-541-343-6812