Application Form
Summer, 2008

YOUR CURRENT ADDRESS:

PERMANENT/PARENT/SPOUSE/OTHER ADDRESS: THIS MUST BE FILLED OUT!

name address city phone (h) phone(w)     state       zip FAX e-mail name address city phone(h) phone(w)     state       zip FAX e-mail

Summer Address (if known). It is very important that we be able to reach you.

name or c/o address city   state phone(home) FAX e-mail zip (work)

DON'T FORGET TO GIVE US A FAX NUMBER---GET ONE FROM KINKOS IF YOU DON'T HAVE A FAX MACHINE AND YOU MUST LIST YOUR PARENT/SPOUSE/SIGNIFICANT OTHER/RELATIVE FOR MEDICAL EMERGENCIES. WE CANNOT PROCESS THE APPLICATION WITHOUT THIS INFORMATION.

DATE OF BIRTH:

PASSPORT NUMBER AND EXPIRATION DATE (Attach photocopy of picture page). You MUST have a current passport with extra pages to apply for this program!

OCCUPATION:

FINAL COLLEGE GRADE COMPLETED:

STATE OF HEALTH: Do you have diabetes, asthma, depression, stomach problems, or any chronic health concerns? Are you capable of walking at least two miles a day? Please list ALL health concerns-this is important (use back side if necessary):

 

ANY TEACHING EXPERIENCE? -- PLEASE GIVE DETAILS: