Valparaiso University Summer Program Application

Summer Program Applying For*


Personal Information


Last Name*
(As it appears on your passport)

First Name*
(As it appears on your passport)

Preferred Name*
(Nickname)

Email Address*

Permanent Home Address*

Phone Number*
(Home Phone) (Cell Phone)

Date of Birth*
(Month/Day/Year)

Gender*
Male Female

Father's Name*

Father's Email*

Father's Cell Phone Number

Mother's Name*

Mother's Email*

Mother's Cell Phone Number

Present/Future Program of Study



Travel Information


Do you have a valid passport? *
Yes No

If yes when does it expire?*
(Please Provide Month/Day/Year of expiration)

Arrival Date and Time*
Please provide us with your exact travel itinerary

Departure Date and Time*
Please provide us with your exact travel itinerary

Have you ever visited the United States before?
Yes No

If yes, where in the United States?



Medical Information (Safety and Well-being)


Do you have allergies to any of the following?*
(Click on the box only if you have allergies to the stated item)
Food
Pets
Medicine
None apply to me

If you are allergic to anything in the above catergories please provide us with details.

Do you have any of the following?*
(Only click on the box of items that apply to you)
Asthma
Epilepsy
Diabetes
Mental Health problems
None apply to me

If you answered yes to any of the above conditions please give details.

To assist us in helping you get the most out of your trip to United States, list 3 or 4 things you hope to gain from the experience or reasons why you would like to go on this trip.


Disclaimer

1. At VU we operate a zero tolerance to weapons, drugs, alcohol, cigarettes and aggressive and abusive behavior. Please acknowledge and accept our policy.
2. At VU students are unable to leave the grounds unless accompanied by a teacher/ chaperone. We would like your support and assistance in this matter.
3. All lessons and activities are compulsory.

Consent

Please input your name and today's date to show you agree to abide by the above school regulations and policies.

Parent Consent and Agreement*
(Full name and today's date)

Applicant Consent and Agreement*
(Full name and today's date)


Please submit this form and U.S. $100 non-refundable deposit to your program director.
U. S. $100 non-refundable deposit will be subtracted from your total cost of the trip.

Contact Information

Office of International Programs
1509 Chapel Drive , Harre Union Room 209
Valparaiso, Indiana 46383
international@valpo.edu
Tel: 001-219-464-5333
Fax: 001-219-464-6868

Mr. Moninder "Holly" Singh
Director of International Students and Scholars