Study Abroad Programs APPLICATION FORM Click for: Graduate Pharmacy Program in the Amazon Click for: Dates of 2010 Program & Student Check List RETURN HOME Use this APPLICATION FORM for ALL GAI Programs |
| Study Abroad Programs Application Form Global Awareness Institute, a 501(c)(3) organization Click for: Graduate Pharmacy Program in the Amazon Click for: Undergraduate Program in the Amazon RETURN HOME Yes, Sign me up! |
Application Form GAI Amazon Programs I am applying for: _____ Study of Medicinal Plants and Culture in Amazonia (graduate program) _____ Development and Cultures of the Amazon (undergraduate) _____ Professional Development Seminar Note: Program acceptance dependent on GAI receipt of an electronic copy of this application. A. GENERAL INFORMATION Name: __________________________________________________________________________________ First Middle Last (As On Passport) Passport Number: ________________________ Expiration Date: _________________________ Date of Birth: _________________________ Gender: _____Male _____Female Month/Day/Year Citizenship: ________________ Country Local Address: __________________________________________________________________________ Street Apt/Box No. __________________________________________________________________________ City __________________________________________________________________________ State zip Address Valid From: _______________ to _______________ Tel. No.: ___________________ E-mail: ____________________ Permanent Address: _____________________________________________________________________ Street Apt/Box No. _____________________________________________________________________ City _____________________________________________________________________ State zip Tel. No.: ______________________ E-mail: ______________________ B. ACADEMIC HISTORY AT INSTITUTION Name of Current College/University: Current Standing: Freshman Sophomore Junior Senior Department of Major Program: Major: Good Academic Standing Required Current GPA: C. MEDICAL HISTORY How would you describe your general health? How would you describe your overall physical condition? (Include regular exercise programs, if any) Please list ALL medications you have taken during the past two years. Are you presently taking any medications? Please list. Are you allergic to any medications? If so, please list. Do you have any other allergies (include insects)? Please list. Do you have ANY health related conditions that GAI should know about? Name of your physician: Address of your physician: Your physician must complete the medical history form we will provide to you as a condition of your acceptance to this program. Forms available from GAI. D. FIELD STUDY FINANCIAL OBLIGATION Program cost: The cost of the Amazon program is $2,700 and includes round trip airfare Lima-Iquitos, lodging and meals at GAI�s rainforest lodge near Iquitos, and scheduled field excursions. Not included are airfare from U.S. to Lima, Peru, personal items, meals while off the reserve, and unforeseen airfare price increases. Financial Aid: Financial aid and scholarships are the responsibility of student participants. Financial aid is available to the extent that it would be for any other undergraduate program of study at NSU. Students should consult the Dean�s Office for complete information on financial aid available for this program. You may be eligible for study abroad scholarships. Application fee: There is no application fee for this program; however, a deposit of $500.00 is required for your application to be considered. Other payments must be received according to the following schedule. Late payments may disqualify you from the program. Payment schedule checklist: Date Due Amount Due Refund Policy ______ With application: $700.00 deposit Fully refundable if not accepted to program; by January 15th (+ $385 for Cuzco)* 1/2 refundable if airline tickets have not been purchased. ______ February 15th $1,000.00 One half refundable before April 15. (+ $300 for Cuzco) ______ April 15th $1,000.00 No refund after April 15 for any reason. (+ $200 for Cuzco) ______ I acknowledge that I have reviewed the costs of this program and accept responsibility for payment. *Payment due dates for optional Cuzco/Machu Picchu tour E. SELF EVALUATION I. Language Skills: Please indicate whether your speaking and comprehension proficiency level is elementary (E), intermediate (I), fluent (F), or no proficiency (N) Spanish: Other: II. How would you rate yourself on the following? EXPLAIN each of your answers in a short narrative response. 1= outstanding, 2= average, 3= needs work, 4= poor, 5= unable to evaluate 1. Listening, comprehension, and retention skills? 1 2 3 4 5 Explain: 2. Communication skills a. In small and large groups of people you know? 1 2 3 4 5 b. In groups of people you don�t know? 1 2 3 4 5 Explain: 3. Independent thinking skills? 1 2 3 4 5 Explain: 4. Ability to work well in groups a. Under normal conditions? 1 2 3 4 5 b. Under stressful conditions? 1 2 3 4 5 Explain: 5. Leadership skills? 1 2 3 4 5 Explain: 6. Ability to withstand a. extreme physical challenges? (e.g. uncomfortable living 1 2 3 4 5 conditions; strenuous walking & rowing, bugs, heat, dirt; little free time, total immersion in a foreign language and culture) Explain: 7. Camping skills? 1 2 3 4 5 Explain: 8. Is there anything else we should know about you to better enable us to assess and serve your needs? III. Please answer the following questions with a short narrative. A. How do you think that your participation in this program will benefit the rainforest and its inhabitants? B. How do you think that this program is going to enhance your character and/or your career? F. TRAVEL HISTORY Have you traveled outside the United States before? Please list all countries visited and what you did there. What was the purpose of your trip? Who did you travel with? Did your travel include service to others? Note to Foreign Students: Foreign students should check with the appropriate officials regarding visas necessary for travel to Peru and mechanisms for retaining the student visa while enrolled in this program. G. APPLICATION DEADLINE The deadline for applications to the Amazon program is: January 15th with an accompanying $700.00 deposit. There is a minimum 15 student requirement for a group. Groups may be cancelled for low enrollment. J. VALIDATING SIGNATURE BY APPLICANT PRINT this page and provide one copy to: Global Awareness Institute (GAI) 2208 S.E. 20th Street Fort Lauderdale, FL 33316 USA I certify that the information given on this form is correct to the best of my knowledge. I agree to sign appropriate release forms and acquire applicable health and travel insurance before embarking on study abroad. Signature: ________________________________________________________ Date: E-mail your completed application form to: [email protected] or mail your form and deposit to: Global Awareness Institute (GAI) 2208 SE 20th Street Fort Lauderdale, Florida 33316 |