Participant Study Abroad Application

 Tropical Marine Biology in Australia
Personal Information

Name:

 
  First Last  
     

 

Middle

 
 

Date of Birth:

 

 

 

Month       Day         Year

 

 

Mailing Address: 

 

 

Street    

City 

 

 

 
 

State

Zip

  
E-Mail:    
Work Phone:    
Home Phone:    
Passport #: Date of Issue:
College where you will be registering for this program:
Phoenix College   Paradise Valley College

Academic Information
 Courses in which you are currently enrolled:
Current College Major:
GPA:  
Minor:  
 
Parent or Custodial Information  
 

Father's Information 

Mother's Information 
Name: Name:
Address: Address:
Home Phone:
Home Phone:
Work Phone: Work Phone:
Fax:
Fax:
 

Financial Information
I am planning to apply for financial aid for my college:     Yes       No
Who should receive the bill for your program:          Self             Parent      Other
If other, please provide name:
 

Additional Information
Please list any other study abroad programs in which you have participated or are applying for at this time:
 

If you wish to identify yourself as a member of an ethnic or racial group, please indicate:

   Black            American Indian              Latin            White            Other(s)
 

Agreement/Applicant’s Signature
I agree to notify the study abroad program instructor of any changes to the information presented on this application.
I understand that my application will be reviewed and can be accepted or denied.
I certify that all information on this application is correct.
I hereby certify that I will have adequate means of financial support for payment of fees.
 
To be printed and filled out:
__________________________________________________________

Signature of Applicant                                                             Date
 
 
To be printed and filled out:

References and Program Approval
To be complete your application must have approval signatures from your department chair your academic advisor.
Name: _____________________________________________    Position:  ____________________
 
Chairperson’s Name: _______________________________    Department:  ___________________
 
College: ___________________________________________    Phone: _______________________
 

I support this student’s decision to participate in this Study Abroad program
_________________________________________________________________

Department Chair                                        Date
 

I support this student’s decision to participate in this Study Abroad program

_________________________________________________________________
Academic Advisor                                                       Date
 
For Office Use Only
Is the student a full time student?
 
Yes   
 
No
Is this student in good academic standing?
 
Yes   
 
No
Has this student ever been involved in any disciplinary problems at your college?
 
Yes   
 
No
Does this student have your permission to study abroad as part of the academic program?
 
Yes   
 
No

_______________________________________________________________________________
Signature Approval of Academic Dean or Appropriate Party at Your College        Date