NAME AND ADDRESS Print your name as shown on your passport
LAST NAME
FIRST NAME
MIDDLE NAME
PREFERRED NAME FOR NAMETAG
E-MAIL
SEX
F
M
CURRENT STREET ADDRESS
CITY
STATE
ZIP CODE
EMERGENCY CONTACT INFORMATION
NAME OF EMERGENCY CONTACT
E-MAIL
RELATIONSHIP
HOME PHONE
WORK PHONE
CELL PHONE
PASSPORT INFORMATION
PASSPORT NUMBER
PLACE OF ISSUE (AS PRINTED ON PASSPORT)
DATE OF ISSUE
EXPIRATION DATE
PERSONAL INFORMATION
NAME OF UNIVERSITY
MAJOR & DATE OF GRADUATION
UNDERGRAD
GRAD
AGE
DATE OF BIRTH m/d/y
RELIGION (OPTIONAL)
HEALTH, ALLERGY AND DIETARY INFORMATION
TRAVEL/MEDICAL INSURANCE COMPANY
POLICY NUMBER
GROUP NUMBER
MEDICATIONS CURRENTLY TAKEN
MEDICAL AND DIETARY LIMITATIONS AND ALLERGIES
ACADEMIC CREDIT
WILL YOU BE RECEIVING CREDIT FOR THIS EXPERIENCE?
YES
NO
FOREIGN LANGUAGES SPOKEN
1.
LEVEL
BEGINNER
INTERMEDIATE
ADVANCED
FLUENT/NATIVE
COMMENTS
2.
LEVEL
3.
LEVEL
PREVIOUS EXPERIENCE & INTERNSHIP GOALS
HAVE YOU EVER TRAVELED OR LIVED IN A SPANISH SPEAKING COUNTRY? IF SO, WHERE AND FOR HOW LONG?
OTHER INTERNATIONAL TRAVEL EXPERIENCES
LIST ALL POTENTIAL AREAS OF INTEREST FOR INTERNSHIP
LIST ANY EXPERIENCE AND/OR PREPARATION FOR YOUR INTERNSHIP
PLEASE LIST THREE LEARNING GOALS YOU HOPE TO ACHIEVE FROM THIS INTERNSHIP
HAVE YOU EVER PARTICIPATED IN A FIELD WORK PRORAM OR INDEPENDENT RESEARCH PROJECT?
LIST ANY HONORS OR SCHOLASTIC AWARDS
REFERENCES: I have asked the following people to write in support of my application
NAME
TITLE
NAME
TITLE
WHAT TO DO NEXT
1. Send this application together with the participation agreement. A health form will follow after we have received your application. You will need to include the $65 application fee and a $500 deposit in order to confirm your reservation. 2. All checks or money orders must be drawn on U.S. or Canadian banks. Checks or money orders from Canadian banks must be in U.S. dollars. Checks must be made out to "PRAXIS CENTER" (not just "Praxis" Banks are very picky about things like this here.) 3. There is a $25 fee for all returned checks. 4. The deadline for receipt of the balance of your payment is 25 days prior to departure. Late final payments must include a $50 late fee and must be a money order or cashier´s check in U.S. dollars. 5. To insure total refundability of your payments, obtain Trip Cancellation Insurance. All interns must have medical/travel insurance. For info. about this, one company we have worked with is HTH Direct, www.hthstudents.com 6. Non-US residents need to contact the consulate of the country(ies) you will be visiting for information about visa requirements. 7. If you are interested in assistance from PRAXIS for obtaining financial sponsorship from your friends and family, check here p and drop a note to PRAXIS at the e-mail address below.
NOTE: WHEN YOU SEND US A CHECK, PLEASE USE THE U.S. POSTAL SERVICE´S EXPRESS MAIL SERVICE. THIS IS SAFER AND FASTER THAN REGULAR MAIL AND IS TRACKABLE SHOULD THERE BE A PROBLEM. WE HAVEN´T HAD GOOD SERVICE WITH FEDEX EITHER. THANKS!
011 (506) 2219-2360, 8835-7802 P.O. Box 025331, #SJO 44689, Miami, FL 33102-5331.