
Complete the application by typing in the boxes indicated. Print and sign and then have your department chair sign as well.

To be eligible, participants must be returning to Longwood in the following fall.
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Participants are required to attend meetings/lectures prior to departure, deliver presentation while in
Ecuador on a selected topic, and make a presentation upon return.
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Cost to participants is approximately $900.
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The first $300 is a nonrefundable deposit and is due upon acceptance into the program.
 If a participant withdraws from the program, he or she is responsible for reimbursing the university for all unrecovered funds (nonrefundable airline tickets, deposits for SELVA tour, etc.).
 See www.longwood.edu/internationalaffairs for more details.
Name:
Department:
Click here to enter text.
Position/Rank: Click here to enter text.
Years at Longwood: Click here to enter text.
Click here to enter text.
Office Location: Click here to enter text.
Telephone:
Email Address:
Click here to enter text.
Click here to enter text.
Courses Taught:
(Number and title)
Click here to enter text.
Please answer these questions as thoroughly as possible.
A.
Describe your previous travel experience:
Click here to enter text.
B.
Explain the reasons for your interest in this program (if it connects to your teaching/research you should discuss this fully):
Click here to enter text.
C.
What can you bring to the group learning experience?
Click here to enter text.
D.
What do you hope to get out of this program?
Click here to enter text.
E.
What are your ideas for meeting the required post-trip presentation (either campuswide or to classes)?
Click here to enter text.
F.
Why should you be selected for this program?
Click here to enter text.

I understand that if selected for this program I must meet the pre and post-trip requirements. I understand that my initial deposit is nonrefundable. Furthermore, should I withdraw from the program, I am responsible for repaying Longwood for any nonrefundable money expended on my behalf including, but not limited to, airline tickets and excursion fees. I understand that I am required to attend a risk session offered by the Office of
International Affairs and to purchase the required travel insurance policies. I must also submit all required paperwork by the deadlines requested. I have answered questions honestly and to the best of my ability.
Name (signed): _____________________________________ Date: _____________________
I support the application of this faculty member. I believe that he/she will meet the pre- and post-trip requirements and will benefit from this experience.
Chair name: (printed) ____________________________ (signed) _______________________