ApplicationfortheUniversityof
NorthCarolinaWilmington
PeaceCorpsPreparatoryProgram
Personal Information: First Name: Last Name: Date: Phone Number: Email Address: Home Address: List below any foreign countries you have visited: Are you an American Citizen? Yes ( ) No ( ) Country Visited: Purpose of Visit: (Vacation, School, Volunteer, other?)
Date and Length of Stay: Whatleadershipactivitieshaveyoubeenapartof?Whatwasyourrole?
WhatexperienceshaveyouhadinAmericawithpaidorvolunteerworkexperiencewith
minorities,underprivilegedpeople,thedisenfranchised,and/ordifferentculturalorethnic
groups?
Academic Information: Major (if declared): Minor (if declared): If not declared, what majors are you considering?: Which semester are you currently in? How many hours completed towards degree?: What is your current GPA?: Are you and American Citizen? What language courses have you taken so far or are currently enrolled in?: Pleaselistbelowanylanguagesspokenwithconversationalfluency:
Pleaselistbelowanylanguagesinwhichyoucanreadand/orwritewithreasonable
comprehension:
Information Regarding Peace Corps Prep: WhyareyouapplyingtothisPeaceCorpsPrepProgram?
IfyouwereacceptedintothePeaceCorps,whatpartoftheworldwouldyouwanttobe
placed,andwhy?
HowdoyouseethisPeaceCorpsPrepProgrampreparingyourforyourcareer,regardlessof
whetheryouenrollinthePeaceCorpsornot?
Doyouhaveanyexperiencetutoringorteaching?Yes()No()
Ifyespleaseexplainbelow:
Doyouhave,orplanonhaving,anyexperiencewithagriculture,forestry,construction,or
anothertradeskill?Ifyes,pleaseexplainbelow:Yes()No()
Doyouhave,orplanonhaving,experienceinahealthcarerelatedfield/health
education/healthoutreach?Ifyes,pleaseexplainbelow:Yes()No()
Intwopagesorless,telluswhatinyourlifehasleadyoutowanttobeaPeaceCorps
volunteer(doublespaced,oneinchmargin,12pt.type).Attachtoapplication.
PeaceCorpsPrepProgramApplication‐UNCW
ReleaseofInformation
I permit the University of North Carolina Wilmington Peace Corps Prep Program to
release information to the Peace Corps about the participants in this program.
Understanding the UNCW Peace Corps Prep Program will detail information about
my progress throughout the program and other information that will help the
Peace Corps gauge the effectiveness of the PCPP. I understand these
educational records are subject to the Family Education Rights and Privacy Act
(FERPA). This act prohibits college officials from disclosing any records, including
grade reports, academic standings, transcripts of records, or any other records
which contain information directly related to the student and from which the
student can be individually identified without my consent.
I hereby permit the University of North Carolina Wilmington PCPP to disclose
personally identifiable information with the Peace Corps regarding my
participation in the Peace Corps Preparatory Program for the purposes of
assessing the PCPP. This information will be limited to my name, my date of
admission to the PCPP, the course work and other activities I selected to satisfy
PCPP requirements, date of graduation, and whether I successfully completed
the PCPP upon graduation.
Student Name (Printed) ___________________________________________
* Student Signature/Date ___________________________________________
Accepted by the director of the UNCW Peace Corps Prep Program:
Director Name ____________________________________________
Director Signature/Date _____________________________________
* Signatures are not required at this time, but form
will be signed upon acceptance into the program.
Submit