Summer Study in Japan Application

Middle Initial

Nickname (if applicable)

Date of Birth

Place of Birth

City/State/Country

Gender

Male
Female

Student ID #

CURRENT MAILING ADDRESS

This address is valid through:

(day/month/year)

Street Address

Box/Apt. No. (if applicable)

City

State

ZIP Code

PERMANENT MAILING ADDRESS

Street Address

Box/Apt. No.

City

State

ZIP Code

CONTACT INFORMATION

Telephone

Include area code

ACADEMIC INFORMATION

Current Academic Status

Freshman
Sophomore
Junior
Senior

Overall GPA

GPA in major

Are you a HEOP student?

Yes
No

Are you an Honors student?

Yes
No

What is your major?

REFERENCES

Please list names and department affiliation of TWO St. Bonaventure faculty, staff or administration members who can attest to your academic and personal character. (At least one must be a faculty member.) Please inform both references that they will be contacted by Dr. Phillip Payne or Christopher Dalton of the SBU Department of History, coordinators of the Summer Study in Japan program.

1. Name

2. Name

Department

PLEASE ANSWER THE FOLLOWING QUESTIONS

As a participant in Summer Study in Japan you will be outside your customary American medical care system, so please tell us about any condition, physical or emotional, for which you are being treated or for which you are taking medication.

Enter "none" if this does not apply.

Please list all medications you are currently taking.

Enter "none" if this does not apply.

Do you have dietary restrictions or food allergies?

Please list restrictions/allergies or enter "none."

AUTHORIZATION & INSTRUCTIONS

I ACKNOWLEDGE that Dr. Phillip Payne and Christopher Dalton have my permission to verify my SBU academic and disciplinary records, including a full review of my transcript, and that this application will not be complete until I have submitted a $250, non-refundable deposit.* (Deposits may be made electronically on my.sbu.edu or by taking a check payable to St. Bonaventure University to the Business Office in Hopkins Hall.)

*If you are not accepted to the Summer Study in Japan program your deposit will be refunded.

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St. Bonaventure University

PERSONAL INFORMATION