Ghana Alternative Winter Break

If you have questions about this form, please contact the Ware Institute at 717-291-4164

Your Name * First Last
Email *
Your daytime/cell phone * - (###) - ### ####
Class Year *
What is your major?
Date of Birth You must be age 18 at time of travel. * / MM / DD YYYY
Have you traveled outside the U.S. before, and if so, where? If you have NOT traveled outside the U.S. state "no." *
PASSPORT AND 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 may apply by mail.

If you have questions about passports and visas, or for more information about passports and visas, please contact Assistant Dean for International Programs and Off-Campus Study Rachel Helwig, in the Joseph International Center. You can also visit their web site.
IMPORTANT: You are required to provide a copy of your passport with this application or NO LATER THAN November 7, 2012. We cannot purchase airfare without your valid passport.
What is your country of citizenship? If you are a U.S. citizen, just indicate "U.S." *
I agree to provide the Ware Institute with a copy of my passport, which must be valid through July 2013, by November 7, 2012.
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 11/7. I need to apply for a passport
INOCULATIONS & MEDICATIONS
You are required to complete a travel clinic by NOVEMBER 28 to determine inoculations, medications, or other vaccines that are required or that you might need. You should check www.cdc.gov for a country-specific list of required inoculations, vaccines or medications.
There are two options for your travel clinic:
1. Your family physician
2. A travel clinic such as Maxim Healthcare
A Yellow Fever immunization card is required and anti-malarial medications are recommended for travel in Ghana; however depending upon your individual health issues you must consult your travel physician. Many medications need to be started weeks in advance of your departure. This is why the deadline to complete your travel clinic is NOVEMBER 15, 2012.
I agree to complete my travel clinic by November 15, 2012. * I agree I must discuss this with the Ware Institute.
PAYMENT
Checks or Money Orders should be made out to Franklin & Marshall College.

NOVEMBER 7: Deposit of $1,400 is due.
This deposit will enable the purchase of airfare and it is important that you make your deposit by this date. Deposits are NON-REFUNDABLE once airfare has been purchased.

NOVEMBER 28: Balance of $1,800 is due.
I agree to make payments on the dates they are due. * I agree I need to discuss this with the Ware Institute I am a CPS Marshall Scholar and plan to use funds for this trip.
I also understand my COMPLETED CPS Marshall Scholar proposal is due 10/5 (or sooner) in order to receive project approval in time.
EMERGENCY CONTACT INFORMATION
Name of your PRIMARY emergency contact. * First Last
Relationship to your emergency contact. *
Email of your emergency contact. *
Cell Phone of your emergency contact. * - (###) - ### ####
Email of your parent or legal guardian *
HEALTH & WELFARE
Are there any dietary preferences/restrictions that the Ware Institute needs to be aware of while you participate in this program? If none please enter "none." *
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." *
In the spirit of community solidarity and engaged learning, Ware Institute programs have a strict conduct policy and are drug free. * I agree to abide by this policy I want to discuss this with the Ware Institute
Please list three things you know about Ghana. *
Of the six issues listed below, which are you most comfortable dedicating yourself to on this trip?
1. Sanitation
2. Nutrition
3. Sports/Physical well-being
4. Entrepreneurship
5. Poverty issues
6. Disease and health education *

These issues will be incorporated into our community service projects, but do not influence what you decide to teach in your courses.
Please list a course subject and brief description of what you would like to teach at the Heritage Academy. *

Your course subject does not have to pertain to one of the topics above.
Name of a faculty member or F&M staff member whom you have asked to recommend you.
We will contact them with a link to a form to complete. * First Last

Ghana Alternative Winter Break

Ghana Alternative Winter Break

EMERGENCY CONTACT INFORMATION

HEALTH & WELFARE