Honduras Alternative Spring Break Application
Honduras Alternative Spring Break Application
March 10-16, 2013
Name - Your name EXACTLY as it appears on your passport. Include middle initial (or name) after your first name, if needed.
*
First
Last
Class Year
*
Major
if undeclared, state "undeclared"
*
I am a Student Health Advisory Committee Member.
Yes
Please provide your cell phone number
*
-
(###)
-
###
####
Email
*
List your date of birth.
You must be age 18 at the time of travel
*
/
MM
/
DD
YYYY
What level of Spanish do you speak?
Spanish is not a requirement of the trip
*
None
Minimal
Pretty Well
Native Speaker/fluent
PASSPORT/VISA REQUIREMENTS
If you are applying for a passport for the first time,
you must hand in your application in person. This can be a lengthy process.
If you are renewing your passport
(you should be sure you have a passport that is valid up to at least six months after the end of your travel experience), you may apply by mail. In either case, you will need two passport-sized photos. Many pharmacies, shipping facilities, and travel service companies provide this service.
For more information about Passports please visit the Office Of International Programs and speak with Rachel Helwig.
Are you a U.S. Citizen?
*
YES
No
If you are NOT a U.S. Citizen, please indicate your country of citizenship.
It is your responsibility to determine if your VISA is in order to allow entry into Honduras and return to the U.S.
I agree to provide the Ware Institute with a copy of my passport, which must be valid through July 2013, with this completed application.
IMPORTANT:
Your application will NOT be complete until we have a copy of your valid passport. Airfare cannot be purchased without this information.
*
I agree
I must get a copy from home and will supply it by 12/4/12
I need to apply for a passport and will supply a copy when I get it
Passport Number
If you do not have a passport number enter all zeros
*
Passport Expiration Date
Your passport should be good for at least six months after your day of RETURN from your trip.
If you do not have a passport, enter all zeros.
*
/
MM
/
DD
YYYY
PAYMENT SECTION
I understand that CARE or the Ware Institute is under no obligation to refund any trip funds after airline tickets have been purchased.
*
I understand and agree
I wish to discuss this with the Ware Institute or CARE
HEALTH & WELFARE SECTION
You are personally responsible for purchasing all required vaccines and medications recommended for your trip. To have the most benefit, you should see a health care provider at least 4-6 weeks prior to your departure dateto allow time for your vaccines to take effect and to start taking medicines to prevent malaria.
You are required to attend a Travel Clinic for this trip.
There are three options for completing your travel clinic.
1. Make an appointment with Appel Health for your Travel Clinic.
Medications and vaccines are usually more economical using Appel Health. Appel usually requires appointments to be made two months prior to your travel date.
2. Make an appointment at another Travel Clinic. Appel Health can refer you to this clinic.
3. Make an appointment through your family doctor.
Acknowledgement of Medical Requirements
*
I agree to make an appointment on or before the designated deadline and purchase any vaccines or medications required by Appel Health or my Travel Clinic provider.
I need to discuss this further with the Ware Institute
DIETARY RESTRICTIONS/ PREFERENCES
Please list any dietary restrictions or preferences you may have.
If you have none, enter "none."
*
All Ware Institute sponsored programs and trips are drug and alcohol free. F&M students are expected to adhere to the F&M Drug and Alcohol policy and their conduct as representatives of F&M must be exemplary. You will be expected to sign and return a completed F&M Code of Conduct form for this trip.
*
I agree to this policy
I wish to discuss this with the Ware Institute
If you have a health or wellness concern that you would like the Ware Institute to be aware of as the staff helps you plan for approved off-campus study, please complete this section of the form. Examples of a health condition include: 1. a current or chronic medical condition for which you need continuing or specialized medical treatment 2. current consultation with a psychotherapist. Official documentation of your health condition will be required. This documentation must be supplied by Dr. Amy Myers, Director of Health Services, and/or Dr. Christine Conway, Director of Counseling Services, as appropriate. If you currently receive accommodations for a disability at F&M and you want your study abroad program/affiliated American program informed of these accommodations in order for the program to plan appropriately for your participation in the program, please complete this section of the form. Documentation of your accommodations for a disability at F&M must be supplied by Dr. Christine Conway, Director of Counseling Services.
If you do not have any health or wellness concerns, the Ware Institute or the program who will oversee your work in the host country needs to be aware of, please enter "none."
*
EMERGENCY CONTACT INFORMATION
Please be sure your information is ACCURATE.
Name of your emergency contact
*
First
Last
Relationship to your emergency contact
*
Email of your emergency contact
*
Cell phone of your emergency contact.
*
-
(###)
-
###
####
ESSAY QUESTIONS
Please keep your response to 250 words or less.
What experiences have you had that you think will prepare you for this trip?
*
What do you think some of the challenges of this trip will be?
*
What do you think you will learn from this experience.
*
SCHOLARSHIP REQUEST SECTION
I am interested in a scholarship for the Honduras Trip.
I understand that my family's Expected Family Contribution (EFC) will be collected from the financial aid office to document my financial need.
*
I Agree
I need to discuss this with the Ware Institute
I understand that I will be required to raise $200 in donations to C.A.R.E., on my behalf, to support my portion of the cost of my trip.
I understand and agree
I must discuss this with the Ware Institute
