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

*Email

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 Christopher Dalton of the SBU Department of History, coordinator 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 Christopher Dalton has my permission to verify my SBU academic and disciplinary records, including a full review of my transcript.

*Authorization Acknowledgment

I have read and agree to the "Authorization and Instructions" provisions above.

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St. Bonaventure University

Please answer all pertinent questions. Questions with an asterisk require a response.

PERSONAL INFORMATION