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AB Participant Application

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Full First Name
Full Last Name
Nickname
Age
Gender
MaleFemale
Campus Box #
Local Address
City
State
Zip Code
Phone Number
 
Email
 
Student I.D. #
Major(s)/Minor(s)
Year at LMU:
FreshmanSophomoreJuniorSeniorGraduate Student
I am studying abroad or planning to study abroad (Please note that if you're studying abroad you will have to find ways to connect with your trip leader to keep you updated.)
Fall 2011Spring 2012
T-Shirt Size
 
 
Special Health Considerations (ie Diabetes, allergies to medication, etc)
Special Food Considerations (vegetarian, no red meat, etc)
FOOD POLICY: By signing this statement, I understand that this is a group travel experience and we cannot always accommodate special dietary needs. It is advised that those who do have special dietary needs bring food with them and/or buy food for themselves on the trip. The Alternative Breaks program will not cover extra meals for those with dietary restrictions. Also, some trips are not located in areas where food can be purchased. Food provided will most likely be unique to the location of the trip.
Digital Signature:
 
Health Insurance Information
Health Insurance Carrier
Identification/Group #s
Insurance Phone Number
 
Emergency Contact Information (We reserve the right to contact your Emergency Contact at our discretion)
Emergency Contact
Relationship to You
Email
 
Primary Contact Number
 
Additional Contact Number
 
 
IDENTIFICATION: I understand that if I am placed on a domestic trip (traveling by air) I am required to bring a government issued I.D. or Drivers License. I understand that if I am placed on an international trip I am required to bring a government issued passport that does not expire at least 6 months prior to return to the U.S.
Digital Signature:
I have a Current Passport:
Yes
No
Name as it Appears on Passport (State I.D. if only applying for Domestic trips)
Passport Expiration Date
Pick date
Clear selection
Passport Number:
Date of birth:(MM/DD/YYYY)
Some trips require partcipants to drive rental cars. Please indicate if you are willing to drive, over 21, and have a clean driving record?
YesNo
STUDENT GPA & JUDICIAL RECORDS RELEASE: I understand that participants in the AB program are expected to have at least a 2.5 GPA and no major judicial infractions that would disqualify participants in this opportunity. My signature below indicates my consent to release GPA and judicial information to the staff supervisor of this program for verification purposes only.
Digital Signature:
The Alternative Breaks program is alcohol and other drug free. This is required for the safety and well-being of all participants, the group as a whole, and the community in which they are serving. As such, absolutely NO alcohol or illegal drugs may be possessed or consumed during AB functions or trips. Should this policy be violated, the participant will be asked to leave the trip at his/her own expense. In addition, the Student Conduct Code and other University policies regarding student behavior are to be observed at all times. These policies will be discussed with everyone who is chosen to participate and full compliance is a mandatory requirement.
Digital Signature:
PAYMENT OF FEES: The applicant understands that the $100 deposit due Oct. 23rd, 2011 (Trip Selection Night, NO EXCEPTIONS) is non-refundable and secures a spot on the trip. The deadline to withdraw from an AB 11-12 trip is 40 days before your trip departure date. See the AB Important Dates page for specific dates. If you do not provide written notice of your withdrawal from your trip by the date indicated you will be financially responsible for all airfare and/or host organization fees that are incurred by CSA. The Applicant recognizes that any outstanding balance of AB costs will be charged directly to the participant’s LMU Student Account after April 1, 2012. Applicant also understands that Alternative Breaks Scholarships are not automatic and are to be requested via a separate application available in on the CSA website.
Digital Signature:
COMMITMENT: By signing this statement, I am committing to all aspects of AB preparation, participation and follow-up. AB group members must participate in the entire AB trip (you cannot arrive late to the trip, or leave early). Participants are required to participate in all education, preparation and fundraising activities for their respective breaks. Finally, all students will be required to attend all AB and group pre-trip meetings (Winter Break: 4 meetings; Spring Break: 6 meetings; Summer: 8 meetings) before their trip. Leaders will be responsible for setting meetings and meeting times in advance that do not conflict with participants' schedules. One unexcused absence is permitted, but for subsequent unexcused absences, participants will be fined $25 (fines will be added to trip fees). In addition, more than one unexcused absence from pre-trip meetings may result in removal from the Alternative Breaks program.
Digital Signature:
I am applying for a scholarship. I understand that eligibility is based on financial need.
Yes
No
 
 
Please list any specific skills you have that are relevant to the Alternative Breaks program (e.g. language, past community service, leadership experience, etc.).
 
Do you speak any languages besides English?
How well?
FluentlyConversationallyA little bit
Have you ever been on an AB trip?
YesNo
(If yes) Location?
(If Yes) Approximate Date
 
I am a(n) RA/PA/RHA (speak with your supervisor before Trip Selection Night to find out which trips you can go on)
YesNo