Mobility International USA (MIUSA) Invites women with disabilities around the world to apply for the 7th

International Womens Institute on Leadership and Disability (WILD)

August 3 - 24, 2013 (Tentative) Eugene, Oregon, USA

PROGRAM AND APPLICATION OVERVIEW

ABOUT MIUSA
Mobility International USA (MIUSA) is a U.S.-based, non-profit organization whose mission is to empower people with disabilities around the world to achieve their human rights through international exchange and international development.

ABOUT THE WILD PROGRAM

MIUSAs Womens Institute on Leadership and Disability (WILD) will bring together approximately 30 women leaders with disabilities from approximately 30 different countries, to strengthen leadership capacity, create new visions and build international networks of support for inclusive international development programming. During the three-week program, participants will take part in workshops, seminars and discussions, conduct on-site visits, and participate in team-building activities, to explore challenges and exchange strategies for increasing leadership opportunities and participation of women and girls with disabilities in international development programs.

PROGRAM SPONSORS

The WILD program is made possible by the generous support of the American people through the United States Agency for International Development (USAID), with technical support provided by the USAID-funded Leadership, Management, and Governance project. WILD is also supported in part by Mobility International USA and the generous sponsorship of local businesses and families in Eugene and Springfield, Oregon, USA.

WHO CAN APPLY: ELIGIBILITY

To be eligible for WILD, you MUST be a:

WOMAN WITH A DISABILITY Citizen and/or resident of a country in the following regions:
Africa Latin America Asia Middle East Caribbean South Pacific

Established leader and/or professional who is:

At least 21 years of age and older NOT an alumna of previous MIUSA exchange programs

Use at least ONE of the following languages:

Conversational English (minimum) Spanish French

Sign Language with at least conversational American Sign Language (ASL) NOTE: MIUSA uses ASL interpreters who are experienced and skilled at providing interpretation for individuals who use different sign languages.

WHO CAN APPLY: QUALIFICATIONS

To qualify for WILD, you must demonstrate:
Personal experience with disability, an understanding of issues, and a commitment to working for the rights of women and girls with disabilities

Membership in an organization led by and for people with disabilities, or by and for women, with particular attention to issues of women and girls with disabilities; or civil society or other organizations committed to the inclusion of women and girls with disabilities

Commitment to and capacity for increasing leadership opportunities of women with disabilities in the community and/or country

Commitment to and capacity for increasing the participation of women and girls with disabilities in international development programs

MIUSA will strive for diversity of geographic region, age, ethnic background, and types of disability in final selection of qualified participants. Applicants meeting the following criteria are especially encouraged to apply:
From rural communities Members of indigenous groups

Have not visited the United States

PROGRAM OVERVIEW
The WILD program will include interactive workshops, site visits and practical activities on priority issues for women and girls with disabilities which may include:

Strategies for implementing national and international policies and legislation, including the UN Convention of the Rights of Persons with Disabilities (CRPD) and the U.S. Agency for International Development (USAID) Disability Policy Educational rights and opportunities including higher education, specialized and inclusive schools, policy and legal rights, services and accommodations for accessibility Health and family issues including parenting, womens health, HIV/AIDS, reproductive health and violence prevention Using the media Strategies for leadership, including networking and coalition building Organizational development and sustainability, including funding resources and strategies, and fostering partnerships with community organizations and businesses Inclusive international development, including exchanging strategies for inclusion with representatives from U.S-based international development organizations and/or human rights organizations Cultural and team-building experiences, including living with a local host family Goals and action planning sessions, including plans for the transfer of information from WILD to other women and girls with disabilities

LODGING, MEALS AND TRANSPORTATION

Delegates will live with a local host family for the majority of the program

Simple and shared lodging at a modest hotel, and three -nights at a beautiful rustic outdoor retreat center will also be provided. Breakfast, lunch and dinner will be provided each day. All supplemental meals, snacks, or personal incidentals will be at the expense of each delegate.

Accessible public transportation will be provided.

Note: Please do not expect luxury accommodations, meals, or transportation.

LANGUAGE
The official languages of the WILD program are American Sign Language (ASL), English, French and Spanish.

Spoken and sign language interpretation will be provided during formal program activities, workshops, discussions and site visits only.

MIUSA uses ASL sign language interpreters who are experienced and skilled at providing interpretation for individuals who use different sign languages.

PROGRAM COST
Accepted participants will be responsible for:
1. $250 USD program fee

NOTE: Scholarships are available based on applicants demonstrated financial need. Accepted participants will be provided with a scholarship application AFTER they have been accepted to the WILD program.

2. Costs related to obtaining a current, valid passport and U.S. visa, including travel costs to

the U.S. Embassy or Consulate in the home country

3. Personal incidentals, including laundry at the hotel, batteries, soap, toothpaste,

international calling cards and mobile SIM cards

4. Supplemental meals, snacks and beverages

MIUSA will provide:

1. Documentation to support applications for a B1/B2 U.S. visa\

2. Roundtrip airplane tickets in economy class for participants to travel from home countries to

Eugene, Oregon, USA

3. Travel health insurance during the WILD program

4. All main meals, lodging, program activities and accessible transportation during the WILD

program

5. Spoken and sign language interpretation during formal program activities, workshops, discussion and site visits.

6. Disability-related accommodations, including sign language interpreters, travel costs for

personal assistants, etc.

APPLICATION DEADLINE: January 13, 2013

APPLY EARLY!
We receive a large number of applications for a very limited number of openings.

Send your application by e-mail (preferred), or fax:

Mobility International USA (MIUSA) / 2013 WILD Email: womenleaders@miusa.org Fax: +1-541-343-6812 Website: www.miusa.org

HOW TO APPLY: DEADLINE: JANUARY 13, 2013

ONE: Apply Early!
We receive a large number of applications. Apply early to allow sufficient time for the selection process, and for obtaining a B1/B2 U.S. visa, if you are selected.

TWO: Complete ALL SECTIONS of the application, which includes:

Section 1: Applicant Information Section 2: Disability Information Section 3: Professional Information Section 4: Essay Questions Section 5: Two Recommendation Forms. These MUST be completed by two people familiar
with your work and qualities as a leader. Family members cannot complete your recommendations.

NOTE: Applications in English are strongly preferred. Applicants will NOT be judged on English spelling, vocabulary or grammar.

THREE: Submit your completed application, including two recommendations, to MIUSA by January 13, 2013
Incomplete applications will NOT be reviewed. Please make sure ALL sections are completed and submitted to MIUSA: Mobility International USA (MIUSA) / 2013 WILD Email: womenleaders@miusa.org Fax: +1-541-343-6812 / Website: www.miusa.org

FOUR: Application review and response

MIUSA will review all completed applications Applications in English are strongly preferred Applications submitted in French or Spanish will result in a slower review process MIUSA will notify ALL applicants via email about whether they have or have not been selected for the WILD program

WILD 2013 APPLICATION FORM

Applications in English are strongly preferred, and will NOT be judged on English spelling, grammar or vocabulary.

Please indicate:

I have completed the application independently: Yes I have completed the application with assistance from a professional interpreter/translator:

No I have completed the application with assistance from a colleague, friend or family member: Yes / No ============================================================================

SECTION 1: APPLICANT INFORMATION

Applicant Family Name: Pamintasih Darsono Applicant First Name: Hasthari Birth Date: Month: May Day: 2 Year: 1977 E-mail Address 1: ari_darsono@yahoo.com E-mail Address 2: ari.darsono@gmail.com Skype Address: ___________________________ Home Address: _______________________________________________________________ City/Village:_________________________________ Province/State: ____________________ Country: _________________________________________Postal Code: _________________ Home Phone/TTY: (______)(____)_____________________ Mobile Phone/Text: (______)(____)____________________ (Please put your phone numbers in the format of: Country code, City code, Local number) ==================================================================================== Do you have a current passport? NO YES Country of Passport ___________________

Passport Expiration Date: Month: ________ Day: ________ Year: ________ ==================================================================================== Do you have a current U.S. Visa? NO YES Type of U.S. Visa: ___________________ Visa Expiration Date: Month: ________ Day: ________ Year: ________

==================================================================================== 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 is your French language level? None ___Beginning ___ Slow ___ Fast ___ Fluent ____

What other Languages do you speak or sign? ____________________________________________ ====================================================================================

Please list two people we could contact if we are not able to reach you:
Personal Acquaintance (i.e. friend, family member) Name: _________________________________________________ Relationship to you: ______________________________________ Email address 1: ______________________ Email address 2: __________________________ Home Phone/TTY: (______)(____)____________ Mobile Phone/Text: (______)(____)______________ (Please put phone numbers in the format of: Country code, City code, Local number) Main contact person at work Name: _________________________________________________

Position/Title: ______________________________________ Email address: ______________________ Work Phone/TTY: (______)(____)____________ Mobile Phone/Text: (______)(____)______________ (Please put your phone numbers in the format of: Country code, City code, Local number)

SECTION 2: DISABILITY INFORMATION

MIUSAs 7th International Womens 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. Physical disability, and may use crutches, calipers, wheelchairs and/or prosthetics Please describe your disability:

_____________________________________________________________________________________

_____________________________________________________________________________________

SECTION 3: PROFESSIONAL INFORMATION

What type of organization would you represent at WILD? Please mark all that apply.
Disabled Peoples Organization Academic Institute (school or university

Government Agency

Women with Disabilities Organization / Wing / Group / Committee

Private Sector

International Development Program

Other (Please specify) ________________________________________

1) What is the name of the organization?

2) What is the organizations website, if applicable?

3) What is the purpose, mission or goal of the organization? (Limit 100 words)

4) What is your position / job title?

5) How long have you been in this position?

6) What are your daily tasks and responsibilities?

Education and future career (employment or volunteer) goals:

1) What level of education have you had (i.e. elementary, secondary school, private school,

technical school, university)?

2) What is your dream or goal to further your education, if applicable?

3) 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 you have 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.

Project Development / Design

Imagine that you have been invited by an organization to submit a proposal for a grant of USD$5,000 for a project that would benefit women and girls with disabilities. PLEASE NOTE: MIUSA does not have funds to support your proposal. This is an exercise in project development.

Using the outline and table below, please describe a realistic project that you could actually implement in your community.
1) Would you implement a new project, or expand and improve a current project? Please

explain.

2) Please list up to five collaborating organizations and describe how they would be involved in the project. Please include at least one international development organization that is working in your community. a. b. c. d. e.
3) Please complete the table below, describing your specific project activities:

Project Name: Overall Goal of the Project: Duration of the Project (Example: 3-months, 6-months, 1-year) Project Timeline of Activities: Specific Activity Activity (List at least 5) Start Date

Activity Completion Date

4) How would you evaluate the project? How would you know whether the project 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 2013 program? Please be specific.

2) Please list: Any previous experience with international exchange programs, trainings or conferences (where, why and when)

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 2013 program.

4) How did you learn about the WILD program?

APPLICATION DEADLINE: January 13, 2013

APPLY EARLY!
We receive a large number of applications for a very limited number of openings.

Send your application by e-mail (preferred), or fax:

Mobility International USA (MIUSA) 2013 WILD Email: womenleaders@miusa.org Fax: +1-541-343-6812 Website: www.miusa.org

Mobility International USA 7th International Womens Institute on Leadership and Disability (WILD)

August 3 - 24, 2013 (Tentative) Eugene, Oregon, USA

Recommendation Form: #1
Applicant Family Name(s): ___________________________________________________ Applicant First Name_________________________________________________________ Applicant E-mail address(es): ____________________________________ Applicant Country: __________________________

Note to Applicant:

Recommendation forms MUST be completed by two people familiar with your work and qualities as a leader. Family members cannot complete your recommendations.

Suggested references include employers, government agencies, or non-governmental organizations (i.e. a womens group, disabled peoples organization, community based organization, education, social services, etc.)

Complete and signed reference forms may be submitted with your WILD application or the reference persons can send the form to MIUSA directly by email (womenleaders@miusa.org) or fax (+1-541-343-6812).

Note to the Reference Person:

The person named above is applying to be a participant in MIUSAs 7th International Womens Institute on Leadership and Disability (WILD) program, in which women with disabilities will strengthen leadership skills, exchange strategies and build networks of support to improve the lives of women and girls with disabilities internationally.

Please return the completed form to the applicant to be submitted with her application AS SOON AS POSSIBLE, or by e-mail or fax to MIUSA directly (see below). (Use extra sheets of paper if necessary).

Thank you.
=====================================================================================

To be completed by the reference person. Please type or print clearly.

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) How long have you known the applicant, and what role(s) does the applicant have in your organization?

3) Why do you recommend this applicant for MIUSAs WILD 2013 Program?

4) Please comment on how the applicant interacts with others in a group setting and in a fast-paced 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 2013 WILD program help your organization to increase the rights of women and/or girls with disabilities in your community?

Name of person giving reference: _________________________________________________ Signature of Reference Person: _________________________________Date: _____________

Please return to the applicant or send via e-mail or fax to:

Mobility International USA (MIUSA) 2013 WILD Program Email: womenleaders@miusa.org Fax: +1-541-343-6812 Website: www.miusa.org

Mobility International USA 7th International Womens Institute on Leadership and Disability (WILD)

August 3 - 24, 2013 (Tentative) Eugene, Oregon, USA

Recommendation Form: #2
Applicant Family Name(s): ___________________________________________________ Applicant First Name_________________________________________________________ Applicant E-mail address(es): ____________________________________ Applicant Country: __________________________

Note to Applicant:

Recommendation forms MUST be completed by two people familiar with your work and qualities as a leader. Family members cannot complete your recommendations. Suggested references include employers, government agencies, or non-governmental organizations (i.e. a womens group, disabled peoples organization, community based organization, education, social services, etc.)

Complete and signed reference forms may be submitted with your WILD application or the reference persons can send the form to MIUSA directly by email (womenleaders@miusa.org) or fax (+1-541-343-6812).

Note to the Reference Person:

The person named above is applying to be a participant in MIUSAs 7th International Womens Institute on Leadership and Disability (WILD) program, in which women with disabilities will strengthen leadership skills, exchange strategies and build networks of support to improve the lives of women and girls with disabilities internationally.

Please return the completed form to the applicant to be submitted with her application AS SOON AS POSSIBLE, or by e-mail or fax to MIUSA directly (see below). (Use extra sheets of paper if necessary).

Thank you.
=====================================================================================

To be completed by the reference person. Please type or print clearly.

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) How long have you known the applicant, and what role(s) does the applicant have in your organization?

3) Why do you recommend this applicant for MIUSAs WILD 2013 Program?

4) Please comment on how the applicant interacts with others in a group setting and in a fast-paced 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 2013 WILD program help your organization to increase the rights of women and/or girls with disabilities in your community?

Name of person giving reference: _________________________________________________ Signature of Reference Person: _________________________________Date: _____________

Please return to the applicant or send via e-mail or fax to:

Mobility International USA (MIUSA) 2013 WILD Program Email: womenleaders@miusa.org Fax: +1-541-343-6812 Website: www.miusa.org