Pacific University College of Health Professions
Education Abroad Application
Name of Applicant:
Current Address:
Telephone number:
E-mail:
Student ID Number:
Current GPA (or academic standing status):
Do you have a current passport?
___ No
___ Yes
Country Issued: ________
Expiration date: _________
Please indicate your perceived level of Spanish language ability
___ None
___ Beginning
___ Intermediate
___ Advanced
___ Native speaker
Indicate the number of YEARS that you studied Spanish during HIGH SCHOOL.
___0
___1
___2
___3
___4
Indicate the number of SEMESTERS that you studied Spanish at the COLLEGE level.
___0
___1
___2
___3
___4
___5+
Describe any additional forms of education you have had in the Spanish Language and
length of study (ex: tutoring, immersion program, etc.):
Describe plans (if any) to improve your Spanish Language skills prior to the trip:
Are you planning on using PU Financial Aid and/or loan assistance?
___Yes
___ No
©Pacific University College or Health Professions, May 2008, Rev 2012
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Are you willing to participate in fund raising events and donation gathering of supplies
during the six-month period prior to the trip?
___Yes
___No
___ Other (explain):
Are you willing to participate in CHP and community presentations for future promotion
of the project during the five months following the trip?
___Yes
___No
___ Other (explain):
Are you willing to complete a feedback evaluation form following the trip?
___Yes
___No
___ Other (explain):
What primary specialty area and population focus do you wish to practice after
graduation?
International travel experience: (countries and reasons, e.g. study, travel, armed forces).
Include length of stay in each country.
Statement of purpose: Give a brief, yet explicit, statement of the reason(s) you would like
to participate in this program.
Future Practice: How do you plan to use this international experience in your future
career?
Additional Information: Please share any additional information that you would like us to
know in relation to your qualifications or reasons for participation in this
interprofessional education abroad experience.
©Pacific University College or Health Professions, May 2008, Rev 2012
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