Guatemala-EMB 495 spring break.

3/3/2017 - 3/11/2017

This application is not complete until a nonrefundable deposit of $500 has been paid to the Office of Education Abroad by November 18. Payments can be made by cash, check (made out to NKU) or credit card (Visa, MasterCard, or Discover). Please contact Michelle Melish at 859-572-6194 or melishm1@nku.edu with questions. Thanks!

ApplicationModels

Personal Contact Information

Please enter name as it appears or will appear on your passport, including suffixes, etc, if necessary.
Your airline ticket will be issued in this name and the names on these two documents MUST be identical.

First Name

Middle Name

Last Name

Preferred Name

Birthdate (mm/dd/yyyy) Enter Birthdate like so: mm/dd/yyyy

Gender

Home Phone Number

Cell Phone Number

Preferred Email (Check Frequently!)

NKU Email

Current Address

Street

City

State

Zip Code

Permanent Address (Same as 'Current'?)

Street

City

State

Zip Code

Emergency Contact

First Name

Last Name

Relationship to Applicant

Home Phone Number

Cell Phone Number

Regularly Checked Email Address

Address Street

Address City

Address State

Address Zip Code

Passport

Passport Image (bmp, gif, jpg, jpeg, png, tiff, or pdf file required. If you don't upload a copy of your passport you must take it to the Office of Eduation Abroad so they can make a copy.)

Current passports must be valid for a minimum of 6 months after the date of return to the U.S.

Special Requirements

Dietary Requirements (i.e. vegetarian, allergies, etc)

Please provide a response. Enter n/a if not applicable.

Other

Please provide a response. Enter n/a if not applicable.

How did you hear about this program?

PARTICIPANTS WILL BE FINANCIALLY RESPONSIBLE FOR THE AIRLINE TICKET AND ANY OTHER UNRECOVERABLE EXPENSES INCURRED BY THE OFFICE OF EDUCATION ABROAD ON THEIR BEHALF. PARTICIPANTS MUST NOTIFY THE OFFICE OF EDUCATION ABROAD OF ANY CHANGES TO THE INFORMATION ON THIS APPLICATION.

I have read, fully understand, and agree upon the terms outlined above.

Provide a digital signature by typing your name confirming the validity of the information provided in this form.