Qatar Leadership Centre

Declaration Form

All Program Participants are required to sign The Declaration Form that states their
agreement to attend the trip and follow the instructions of the Nominated Trip Leader,
follow the trip schedule and abide at all times by the laws and regulations of Qatar and
the destination. Third party institution representatives should also countersign the
Declaration Form stating the institution’s approval for the individual to attend the study
trip. Further details on Declaration can be found in the QLC HR Manual.

1. Name (Participant)
Person Completing this Form Rooda Omran N A Al-Qebaisi
Age 39 - Years
Program Currently Pursuing Executive Leaders Program 2020-2021

2. Emergency Contact Information

Name Nasir Al-Omran Al-Qebaisi
Telephone Number +974-66222014

3. Special Support Needs

Yes No
Do you have any Special Support
Needs? ☐ ☐
In the space below, please elaborate on your requirements and explain how QLC staff
can accommodate to your needs.

Yes No
Would you like someone to
accompany you for your Special
Support Needs? ☐ ☐
If you have selected “Yes” for both then please fill out below:
Name of person accompanying you

Nationality

Telephone Number
 Qatar Leadership Centre
Declaration Form

4. Accompanied by Husband/Mahram
Yes No
Will your Husband/Mahram
accompany you on this trip? ☐ ☐
If you have selected “Yes” then please fill out below.
Name of person accompanying you

Nationality

Telephone Number

Please note that the Husband/Mahram expenses will not normally be covered by QLC

Rooda Omran N A Al-Qebaisi

I, ______________________________________ (Your Name), hereby agree to attend the study

trip organized by QLC from 07/09/2021 till 15/09/2021.

I will follow the instructions of the Nominated Trip Leader, follow the trip schedule and
abide at all times by the laws and regulations of the destination and home country. In
the event that I do not attend/complete the study trip and do not provide good reason
for doing so, I may be required to pay back study trip payments I have received in part
or in full.

DATE 01 - 07 -2021
SIGNATURE