DE ANZA COLLEGE
VIET NAM in VIET NAM—SUMMER 2012
Professor Karen Chow, English Faculty, chowkaren@fhda.edu, 408-864-5673, Professor Vu-Duc
Vuong, vuduc.vuong@gmail.com,
APPLICATION
Name (Last, M., First):
_______________________________________
Email: ______________________ SID:_______________________________
Passport # and expire date__________________
Home phone: __________________
Home address:
cell:
Birth date: ________
____________________
__________________________________
__________________________________
Are you a college graduate? Yes _____
If yes, school and major:
Zip: _________
No _____
________________________
____________
If still in school,
How many college credits have you accumulated? ____________
At what school(s):
________________________
Your most recent GPA:
Major: ___________
_________
(If applicable, I’m still in High School : ____
School’s name : _____________________
Will graduate in : __________)
Contact(s) in case of emergency:
Name: __________________________
Phone: ______________________
Relationship: _____________
Cell phone:
___________________
Email: ______________________
Address:
_____________________
____________________
(Use the back of this page to list more than one contact.)
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If you are under 18, your parent(s) or guardian(s) name, phone, email and address:
(List as many as appropriate. Use the back if necessary)
_____________________________
________________________
_____________________________
________________________
You’ll enroll for at least 9 Units. Please indicate which courses you would like to take:
( )ANY EWRT or ELIT___________________(Level Requested)
( ) SOC 5 (Sociology of Globalization.)
Do you have health insurance?
What type/insurer:
Yes _____
No _____
___________________________
(Attach a photocopy of the health card or policy.)
In addition to your current health insurance in the U.S., you’ll have to purchase an international
health coverage, through De Anza as a group. The cost for this insurance varies with age but is
quite low, around $45.
Your family/personal physician’s name, phone, email, address:
___________________________________
Are you a U.S. citizen?
Yes _____
No _____
If not, what is your status in the U.S.: ___________________________
Do you have a valid passport:
Yes _____
No _____
(Attach a photocopy of the main page of your passport.)
Do you have any health issue or chronic illnesses? Yes _____
If yes, please list them:
No _____
___________________________
___________________________
Do you take any prescription medicine?
If yes, please list them:
Yes _____
No _____
___________________________
___________________________
Do you need any special accommodation about health, or diet?
Yes ____
No ____
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If yes, please list them:
___________________________
Do you need/want any religious accommodation?
What kind(s) of accommodation:
Yes _____
Do you plan to extend your stay in Viet nam beyond Aug 12?
Yes ____ No ____
If yes, when do you plan to return to the U.S.?
(We need this date to get your round-trip ticket)
No _____
__________
Do you have any contact(s), family, relatives, friends in Vietnam: Yes ____
No ____
Give at least one such contact (name, phone, address, email) just in case:
________________________
_____________________
Lodging: Do you want single ____ or double _____ room?
(There’ll be an additional charge for single room)
Do you speak ___
How well?
read ___
write ____
understand ____ Vietnamese?
______________________________
Have you ever been to Viet Nam?
Purpose of previous trip(s):
When? _________
________________________________
This portion is to apply for scholarship:
Do you need financial aid:
Yes _____
No _____
(Scholarships are generally capped at $500, based on need)
(If you do need financial aid, please answer the following questions:
How much money did you personally make in 2011?
$ ___________
How much money did your parents make in 2011?
(if you are under 25 years old)
$ ___________
Do you receive any government grants, student loans, work study, etc…? Yes ___
What kinds? ________________
How much?
No ___
___________________
________________ )
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Do you live at home with your parents or guardians?
Yes ____
No ____
If you’re no longer in school, what is your current occupation and your employer:
___________________
______________________________
Please return this application, with a $500. deposit, before April 20, 2012; or earlier if possible.
Please sign here:
________________
Parent’s signature (if you’re under 18):
Date: ______________
_______________________
*** Please print the application form, fill it out, sign it, and mail it back to us with a copy of the
front page of your passport and a deposit check of $500. The deposit is refundable until June 18.
Mailing address:
Prof. Karen Chow
English Department
De Anza College
21250 Stevens Creek Blvd.
Cupertino, CA 95014
THANK YOU FOR YOUR INTEREST and APPLICATION.
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ON A SEPARATE PAGE, HELP US MAKE THE TRIP MORE USEFUL FOR YOU.
What is/are your interest(s) in Viet Nam?
Please write about your own experience with Viet Nam or Vietnamese; and what are you looking for in
VN with this course?
What do you plan to major in school, or what is your current profession, and how would you want to
incorporate this summer program in your studies/career?
Anything else you’d like to tell us that may be relevant to this course/trip?
Any particular wish you’d like to fulfill during this trip? (we’ll try to the extent possible)
How did you hear about this course?
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