Form

WHRD Window Application Form – Flexible Funding Modality

Country of Origin*

Current Location (*if different from origin)

First name*

Last name*

Age *

Number of Dependents 0-17 Years at risk/supported through this application*

*A dependent is a child under the age of 18 or family member residing with you and who you are responsible for their care and well-being. If no dependents, enter 0

Number of Dependents 18+ at risk/supported through this application*

*A dependent is a child under the age of 18 or family member residing with you and who you are responsible for their care and well-being. If no dependents, enter 0

Secure email address*

*A secure email address is an address you are OK to be contacted through to further discuss your application. If you feel that contact with WPHF may put you at risk we suggest that at minimum you use a secure computer, safe internet connection and open a separate, new email account and provide this address in the application instead.

Country Code*

Phone number/WhatsApp*

Were you referred by a UN agency, another international organization, or a non-governmental organization?*

Fonds des Femmes pour la Paix et l’Action Humanitaire

ONG/Société civile

Agence des Nations Unies

Autre

If yes, please specify organization

Is this application being completed by yourself or a third party? *

Completed myself

Completed on behalf of a WHRD

If the application is completed on behalf of a WHRD, please provide your contact information.

Full name

Email of applicant

Secure telephone number

Affiliated Organization (if applicable):

1. Please briefly describe your experience as a woman human rights defender. How have you been peacefully leading human rights activities in your community / country ?*

Word Limit: 250

2. What targeted threats have you faced or fear to face because of your human rights / peace activities? *

Word Limit: 200

3. If applicable, when did those targeted threats happen?*

Word limit: 100

4. Please describe how do these targeted threats currently impact your and / or your dependents’ security situation. *

Word Limit: 250

5. How do these targeted threats affect your ability to continue your work?*

Word Limit: 250

6. What do you urgently need to protect yourself and / or your dependents and to sustain your human rights and peace activities? *

Word Limit: 250

7. Please note if not all needs can be covered, which ones are a priority to improve your security situation.*

8. Please specify how much funding you are requesting in USD.
*Please note the maximum amount that can be requested is $10,000 USD

Item 1*

Budget 1*

Item2

Budget 2

Item3

Budget 3

Item4

Budget 4

Item5

Budget 5

Total Budget*

9. Estimated duration this funding will contribute to your safety (months).*

Please note the maximum duration of the support is 6 months.

10. For us to be able to assess your application, please provide the name and contact information of at least one reference, from a national or international organization, who knows your work. This reference should NOT be a family member.

Reference 1 (mandatory)*

Full Name*

Organization*

Email*

Reference Telephone/Mobile*

*include country code

Reference 2 (Optional)

Provide full name, affiliated organization, email address, telephone/mobile

11. Please let us know if you have submitted a similar application to another organization, and/or received support ( financial / non-financial) from one before, as this will help us with coordination. *

Please note this question is for information purposes only and is not evaluated.

Yes

If yes, please name the organization, and explain what will/ was covered

I agree that my application can be transferred to an INGO partner of the WPHF Window for WHRDs*