Name As It Appears on Passport: Sheena Charise Washington

Participant Application Form

Thailand Study Tour on Engaged Buddhism

Summer 2011

Personal Information

Participant Name:______

SMCM ID:______

Seeking SMCM degree?  Yes  No GPA:______

Year in school while abroad (i.e. Jr) ______Gender: ______

Major(s) ______

Faculty Advisor:______

When does your passport expire?
If you do not currently have a valid passport, you need to apply for one now. Learn more at: http://www.travel.state.gov/passport/get/get_840.html

Contact Information______

Local address: ______

Campus or local phone: ______

Preferred e-mail: ______

Responses

Please describe briefly why you are interested in participating in this study tour. What do you hope to accomplish while participating in the program?

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What contributions do you see yourself making to the group of students and faculty who will be living, traveling, and working closely together in Thailand?

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What concerns do you have about participating in this study tour or traveling to Thailand?

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Travel History

List any previous international travel experiences including dates, length of stay and destination:
(i.e. 2004: Italy, 2 weeks).

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Dietary Restrictions

Participants should plan to be more flexible about their dietary preferences while traveling. With that said, list here any strict dietary restrictions you may have and please be specific (i.e., vegetarian with no eggs, no dairy; allergic to all foods with peanut oil; etc.):

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Recommendations

Please provide names and contact information for two faculty members who would be willing to speak with the study tour leader to provide a personal and academic reference for you.

Name:______Name:______

Dept:______Dept:______

Statement of Understanding

Please read the following statements and sign below:

• I understand that it will be necessary for the International Education Office to obtain certain information about my academic and non-academic record in order to: 1) ascertain my eligibility and suitability to participate in study abroad and 2) facilitate my participation. I hereby grant permission to the international education coordinator and/or designee to obtain information that is appropriate to my application and participation in study abroad including, but not limited to, letters of recommendation, permanent academic records and transcripts, conduct, fiscal records, medical records, all for the purposes of study abroad advising and participation.
• I give permission to the international education coordinator and/or designee to contact appropriate personnel in order to verify that I am under no disciplinary action for violation of codes of academic and student conduct and/or that I have no judicial cases pending which would invalidate my eligibility for study abroad.
• I hereby release information contained in my application, letters of recommendation, transcripts, and other information required as part of the application process to the international education coordinator, designee, and those individuals/committees responsible for reviewing and approving my application for participation in study abroad.
• I understand that I am personally responsible for program costs incurred by the College based on my commitment to participate in an SMCM program abroad. If I cancel my participation in the St. Mary’s program, any funds that are non-refundable to the College will be charged to my student account.

Signature: ______Date: ______

• An Initial deposit of $100 is required with the application, which will be refunded if your application is not accepted. Please make the check payable to SMCM.

10/05/2007