PRAXIS CENTER APPLICATION FOR SERVICE LEARNING TRIP
TRIP INFORMATION
TRIP DATES
COUNTRY(IES)
COST
PROGRAM CHOICE - TYPE OF TRIP
Nursing
Central American Culture, History, Politics
Pre-med/allied health/physical therapy
Ecology, Sustainable Development
Public Health
Theology, religious life
Education
Other (please specify)
Social Work
Engineering
Civil
Electrical
Mechanical
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
COUNTRY
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
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 INTERNATIONAL TRAVEL EXPERIENCE
WHAT TO DO NEXT
1. Return application with the "PARTICIPATION AGREEMENT". 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 de Costa Rica" 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. Group members must have medical/travel insurance. 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!
Office: 011 (506) 2219-2360, Cell: 011 (506) 873-0929 P.O. Box 025331, #SJO 44689, Miami, FL 33102-5331