Participant Application and Information: Applications Due July 1st

Complete front and backand return to the Office of Student Life Campus Center Rm. 005 by July 1st.

Please keep a copy for your personal records.For questions, and more information, contact:

Nik Sushka, Service Learning Coordinator, , 240-567-5261,

or Kara Musselman, Program Assistant, , 240-567-4217.

Name: ______M#:______

Date of Application: ______

Expected Graduation:______Major: ______

Current Address:______

Phone:______E-mail:______

Date of Birth :______Male/Female/Self Identified:______

Dietary restrictions: ______

Physical or medical information that might affect trip planning:______

______

*Total trip costs will be approximately $60. Need help paying for the trip? Apply for an Alternative Breaks Engagement Scholarship. Stop by the Office to pick up an application.

What is expected of me??

Before returning your application, please read these expectations of participants.Consider them seriously and sign to indicate your agreement. Thank you.

  • Attend pre-break orientation.
  • Participate fully in service as arranged by the host agencies.
  • Be sensitive of the different cultures and people you will experience.
  • Process the alternative break experience individually and with your service team through reflection activities.
  • Completewaivers, medical forms, surveys, and evaluations as given.
  • Fulfill financial obligation

Alcohol and Other Drug Free Policy

Alternative Break promotes an alcohol/drug-free environment. This prohibits alcohol consumption or illegal or irresponsible drug use by anyone, regardless of age, while participating in Alternative Breaks (including the days of travel to and from the site).Support of this policy by all involved is essential for a safe and socially aware break.

I have read the expectations and policy printed above. I agree to abide by the alcohol and drug free policy and to invest the time, energy, and commitment required of an Alternative Break participant.

______

SignatureDate

Application Questions (please answer on a SEPARATE piece of paper):

We may contact applicants to clarify responses, but please be specific, using examples & explanations.

  1. What do you hope to accomplish on this trip?

What qualities,experiences,and/or skills do you posses that would help you accomplish this?

  1. Please describe activities and organizations you are involved in, on or off campus.
  1. How might you share your learning experience when you return home?

What specific type of projects or activism would you like to get involved with when you return?

Alternative Breaks. Don’t just take a vacation. Make a difference.

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