First Name: Middle Name: Last Name: Gender: Male Female Class Year: Email Address: Date of Birth HC ID Number PO Box: Major 1 Major 2 Minor/Concentration Passport Information Do you have a passport valid through 12/31/2012? Yes No Expiration date Country of Citizenship Place of Birth If not US citzen, do you have legal residency status(green card)? Yes No Program Choice Alternate Choice Academic Recommendation (Letter of Reccomendation from faculty member or advisor - CANNOT be from director of program you are applying to.) Name Department Are you applying for financial aid for summer program? Yes No Permanent Address Street City State Zip Code Parent/Guardian #1 Drop-down List --Select One--Mr.Ms.Mrs.Other Name Relationship to student Street City State Zip Home Phone Business Phone Cell Phone Email Parent/Guardian #2 Drop-down List --Select One--Mr.Ms.Mrs.Other Name Relationship to student Street City State Zip Home Phone Business Phone Cell Phone Email Waiver I hearby authorize the release of my academic records and all medical records, including mentalhealth records, to the Study Abroad office. I also authorize the Study Abroad office to further release any ofsuch records taht they deem relevant or necessary to Study Abroad's agents in the country where by StudyAbroad program occurs. Signature Date
