Medical, Physical, Dietary, Or Other Personal Considerations

Personal Particulars:

Full Name (As it appears in passport):
Please underline surname
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☐Male
☐Female
Date of Birth(mm/ dd/yyyy):
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Birth Country:Click here to enter text.
Citizenship:Click here to enter text.
Country of Residence:Click here to enter text.
Address:
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Postal Code:
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Mobile Number:Click here to enter text.
Home Number: Click here to enter text.
Indicate the program/ themeof choice:
i.e. Civic Engagement or Social Entrepreneurship
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Emergency Contact Details:
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Relationship:Click here to enter text.
Contact Number:Click here to enter text.
Email Address:Click here to enter text.

Medical, Physical, Dietary, or Other Personal Considerations:

Please describe any pre-existing medical conditions, including any prescription medication you may be taking, allergies, or other dietary or personal consideration. This will not affect your selection, but will enable the host institute to make any necessary accommodations.

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If currently studying, fill in the table below:

Educational Institute:
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Semesters Completed in School:
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Memberships in Associations, Clubs, Etc. (Please include dates):
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Work and Volunteer Experience (Please include dates):
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If currently working, fill in the table below:

Designation and Place of Work:
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Number of Years since Graduation:
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Memberships in Associations, Clubs, Etc. (Please include dates):
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Work and Volunteer Experience (Please include dates):
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Previous Experience in the United States:

From / To / Purpose
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Family Residing in the United States:

Note: This will not affect your application

Do you have close family residing in the U.S.?Yes ☐ No ☐

If yes, please fill out the following section; if no, write “None”

*Please include city and state (E.g. John Doe—Chicago, IL)
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Evidence of English Fluency:

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Personal Statement:

Tell us about yourself and your goals including the following: Your background and/ or interests that make you competitive for this particular program (please be as specific as possible). What will you contribute to the group? How do you expect this experience to affect your future academic and professional career? How will it affect you personally? Please structure your essay in paragraphs and limit your response to 250 words, or approximately half a page, single spaced.

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