EmailMe Form - Study Abroad Application: South Africa

Name

First Last

Email

Student ID Number

Phone

### - ### - ####

Gender

Male

Female

Race / National Origin

Date of Birth

MM / DD / YYYY

Please indicate your housing status:

On-campus

Off-campus

Off Campus Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Emergency Contact

Name

First Last

Relationship

Phone

### - ### - ####

Email

What is your degree/major?

What is your student classification?
(Freshman, Sophomore, Junior, or Senior)

Are you currently or have you ever been charged with or subject to disciplinary action for scholastic or any other type of misconduct at any educational institution?

Yes

No

If yes, please explain.

Have you ever been charged with a violation of the law which resulted in, or if still pending could result in, probation, community service, a jail sentence, or the revocation or suspension of your driver’s license?

Yes

No

If yes, please explain.

Do you currently have an active passport?

I understand that my application is not considered complete until the $250.00 program application fee has been paid. I also understand that seats for the program are limited and are managed by the Faculty Program Director, Beth Thornton.

Yes

No

I understand that failure to pay for the program on time or follow the designated payment plan may result in my removal from the program without refund.

Yes

No

Please provide a one-to-two page essay on the following topic:

"Why I would like to participate in this study abroad program."