India Alternative Break Application

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Student Information

Name (Required)

Student ID (Required)

Your E-Mail Address (Required)

Gender

Male
Female

Birth Date (Required)

Land Phone (Required)

Cell Phone (Required)

Citizen of (Required)

Address (Required)

City (Required)

State (Required)

Zip Code (Required)

Ethnicity (Required)

Classification (Required)

Do you have a current US passport? (Required)

No
Yes

Passport Expiration Date

/ /

Please list the languages spoken and level of proficiency for each (Required)

Extracurricular Activities and Student Organizations (Required)

International experience, study or travel - Please lists places, purpose, and dates. (Required)

What would you like to learn or expereince from traveling to India? (Required)

How did you find out about the India Alternative Break program? (Required)

Why do you want to travel to India with this program? (Required)

Have you ever been charged or convicted of a crime? Please explain. (Required)

Do you have any medical or psychological condition that would affect your participation in the program? Please explain (Required)

Authorization (Required)

I authorize the University of Louisville International Service Learning Program staff to access my educational and financial records maintained by the University of Louisville or other intuitions I have attended and to share those records with the ISL Program Coordinators as needed.

Certificate (Required)

I certify that the information I provided on this Application is correct and agree to notify the ISL Program if there is a change in circumstances which might compromise my success in participating in the ISL Program

Waiver (Required)

Under the provisions of the Family Educational Rights and Privacy Act of 1974, I waive my right of access to my ISL Academic Reference

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India Alternative Break Application

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