APPLICATION FORM
SEMESTRE EN MÉXICO PROGRAM
College of St. Scholastica for Fall 2009
NAME_____________________________________ PHONE _______________________
SCHOOL ADDRESS________________________________________________________
DATE OF BIRTH ___________________ EMAIL ADDRESS________________________
PERMANENT ADDRESS____________________________________________________
PHONE _____________________
PARENTS/GUARDIANS ____________________________________________________
ADDRESS________________________________________________________________
PHONE ______________________ PASSPORT NAME ______________________________
Present Class (08 - 09 school year)
First Year Student
Sophomore
Junior
Senior
Major_______________________ Overall College GPA
Names of 3 references: advisor and faculty or staff. For first year students a high school teacher is also
acceptable.
1. _________________________2.______________________ 3.__________________________
Please provide these individuals with a copy of the reference form and have them forward it to Jay
Newcomb, Tower Hall, Center for Just Living located in the Union.
After notification of acceptance, it is necessary to deposit $100 toward the program costs to reserve a
place in the program. This deposit is not refundable after May 1.
INDEMNITY AGREEMENT
I, the undersigned,
• Authorize the trip leaders to review my academic transcript and to consult with faculty and staff to
determine the appropriateness of my participation in this program.
• Understand that I am expected to inform the faculty members in the program of all my private
travel plans associated with the program.
• Agree to indemnify and hold harmless the College of St. Scholastica, Duluth, Minnesota, from any
and all liability, loss, damage or injury incurred to me during the period of the program.
• Agree that I shall be fully responsible for higher costs that may be due to currency revaluations,
unexpected high rate of inflation, fuel shortage or premature departure from program.
Signed ______________________________Date __________________
Cancellation and refund policy.
• $100 deposit is not refundable after May 1.
• Program fees will be refunded in accordance with CSS tuition and fees refund policy.
• Room and Board are refundable on a cost per day basis.
• Airline tickets are not refundable after they have been purchased for the group.
• The cost for changing airline reservations after they have been purchased, and all other related
costs, is the student’s responsibility. This applies to voluntary changes and dismissals from the
program.
Please complete these questions:
How did you develop an interest in this program?
Why do you want to participate in this program?
How will this program fit into your academic and career goals?
Describe your previous intercultural experiences, if any. How have these, or other experiences,
prepared you for the challenges of adjusting to a new culture and lifestyle?
What does your family think about your participation in this program?
This program will emphasize learning within the context of community. How do you see yourself
functioning in this type of environment where a considerable amount of time will be spent on group
processing and reflection on learning experiences?
Describe a stressful situation you have been involved in and how you dealt with it.
Describe an interpersonal conflict you have been in and how you handled it.
What has been your involvement in social justice issues?
What will you bring back to campus from this experience?
Do you have any dietary, disability, medical or emotional needs which may require special
consideration or may require professional care? How will this care be provided during this trip? Failure
to disclose this information may jeopardize your participation in the program or result in early dismissal.
Language proficiency:
How would you describe your level of Spanish language proficiency? Good Fair Poor
Check off the Spanish language courses have you taken at CSS:
Beginning Spanish: __ 1101 __1102 __ 1103 __1104 Intermediate Spanish: __2101 __ 2102
Advanced Spanish __ 3000 level
Other Spanish-related coursework: Please describe any other language course or experiences you
have had, e.g. high school Spanish, semester abroad, course at other institutions.
2009 revision
2