Name

Family Name

Given Name/s

Date of birth

Sex:Female Male

Occupation

Address

Street

Town

State Postcode

Country

Telephone/E-mail

Home Work

E-mail Fax.

PROGRAM CHOICE

MID YEAR  END of YEAR

2-Week  4-Week  6-Week

Level of Study

I  II  III  IV  V

Are you a university student taking the six week program for purposes of accreditation?  Yes   No

Do you require a brief course outline for prior tertiary approval?  Yes   No

CULTURAL MODULE

The Cultural module is a compulsory part of the program. You must follow ONE course out of either of the lists below. Please indicate your 1st and 2nd preference by typing 1 and 2 into the boxes beside each choice

Group A

 Ethnic & Religious Diversity in Indonesia

 Indonesian Women Studies

 Rural & Urban Development

 Business in Indonesia

Group B

 Cooking

 Batik

 Self Defence

 Traditional Dance

You can take an extra cultural course for an additional fee. To avoid tine table clashes please select an option from a group different from your first preference nominated above.

Extra course

ACCOMMODATION

Homestay

Single Hostel

Twin-share Hostel  - sharing with

Single Guesthouse

Twin-share Guesthouse  - sharing with

CONTACT ADDRESS

(in the case of an emergency)

Name

Address:

Telephone:

HEALTH

Do you suffer from chronic or recurrent illness, and have you been seriously ill in the past two years? If so, please specify:

If you have suffered from chronic or recurrent illness, and have been seriously ill in the past two years, please send along with your registration form a doctor's statement declaring your fitness to travel.

1. I am the parent or the legal guardian of the person named above, who will be under the age of 18 years while attending the Salatiga Program; Intensive Course in Indonesian Language and Culture.
2. I acknowledge and understand that it is my responsibility for making arrangements in respect to travel and medical insurance.
3. I accept full responsibility for the care and conduct of the above person while he/she is attending the Program and release the University, its employees, servants and agents from any and all liability arising from any accident which may occur to or injury suffered by the above person; or from destruction or damage to any property of the above person while undertaking the program.