Microsoft Word - Student Form 2008

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Helen Bader School of Social Welfare
INTENSIVE SPANISH FOR SOCIAL WORK PRACTICE
GRECIA, COSTA RICA
JUNE 19 – JULY 10, 2010
STUDENT APPLICATION FORM
Please save in a Word file, complete the form, and email to your recruiting professor.
NAME: Last:
First:
Middle:
Please indicate any variation on first name preferred for the Name Tag:
ADDRESS: (Current):
ADDRESS: (Permanent):
TELEPHONE: (Cell) :
E-MAIL:
(Home):
(Work):
(Other):
UNIV/COLLEGE:
Enrollees may choose to register from the following program options:
Registering as an:
Undergraduate Student (SW 297)
Graduate Student (SW 497)
Continuing Education Professional
I am a:
BSW student
MSW student
I plan to participate in the:
Full 3-week program, June 19 – July 10, 2010
I am willing for the above name and address detail
to be included in the participant list:
Gender:
yes
M
F
no
Age:
20-29
30-49
50+
Can we include your age group in the participant
list?
yes
no
Please provide a paragraph summarizing your professional and volunteer experiences (fields of
service, populations served, etc.)
Describe how you may use your Spanish language skills in the future :
Costa Rica Application - 2010
SELF-EVALUATION OF YOUR LANGUAGE SKILLS AND LEARNING NEEDS:
1. Habla Espanol?
Si
No
2. Are you of Hispanic/Latina/o/Chicano heritage
If “Yes”, from which country/ies:
Yes
No
3. Please rate your own Spanish-speaking ability (check all that apply):
None
Can understand some spoken Spanish
Can read at beginning level
Can speak at a beginning level
Can speak beyond a beginner level, can converse with native speakers.
Can speak Spanish fluently, could get around alone in a Spanish-speaking
country.
Have worked with, or do work with, Spanish speaking clients in a social work setting.
Describe:
4. How many years of formal Spanish instruction have you had?
High School years
College years
Additional Spanish classes, immersion experiences, or travel? Please describe:
ACOMMODATION PREFERENCES
While at ACCE in Grecia, we stay with local host families. Each provides students with:
a single bedroom, desk, shared bathroom with family; family-style breakfast, dinner and
conversation en Espanol. The following information is needed to select your accommodations:
Ground floor essential:
Need special diet:
Yes
Yes (details:
No
Are you a smoker?
)
No
Allergies?
Yes
No
Yes Explain:
No
I prefer a host family with (check all that apply):
children
without pets
another ACCE student, name
I have no preference
Other
an older adult
Do you have any disabilities that would prevent you from climbing one flight of stairs and walking
for about 20 minutes?
Yes No
Note: In our third week of Service-Learning at Roblealto School we stay in a guest dormitory all
week and share meals with the children and staff. A bit like a summer camp, it will afford less
personal privacy and much collaborative effort, and hopefully, huge dividends in language
competence.
DEADLINES:
 Deposit in the amount of $300.00 is due to the Center for International Education on or
before March 15, 2010
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