first name:
middle initial
last name:
date of birth: MM/DD/YYY
email:
cell:
street:
apartment/unit
city
state
zip code
do you hold a current passport
country in which passport was issued
passport number
passport expiration
undergraduate or graduate
year (1st, 2nd, 3rd, etc)
college
department/unit
cumulative GPA
have you participated in other study abroad programs? (yes/no)
in which country?
duration of the program?
have you travelled independently outside of the US? (yes/no)
in which countries?
duration of independent travels?
have you ever been accused, arrested or convicted on felony charges
or been the subject of a deportation order? Please explain if yes.
Do you have any physical or mental conditions that could be a factor
in your safe travels and successful completion of the program?
do you currently hold first aid certification?
do you hold any religious beliefs that may preclude you from any of
the activities of the program?
Do you have any known allergies to any food or medicines?
Comments:
