University of Kentucky, Department of Geography SUMMER 2000 PROGRAM IN OAXACA, MEXICO

Director – Dr. John Paul Jones, please print out and hand in 3 copies

Date: _________________________ Social Security #: ___________________________

Name: _________________________________ Local Phone: ________________________

Local Address: ________________________________________________________________

(Residence Hall or Street Address) (Zip or Speed Sort)

E-mail address: __________________________________________________________

Permanent Address: ____________________________________________________________

(Street Address) (City) (State) (Zip)

College & Department: _______________________________________ Major: __________________________

Status: q Freshman q Sophomore q Junior q Senior q Graduate

Academic Advisor: ____________________________ GPA: _____________ Age: ____________________

Do you plan to apply for Financial Aid for this program? q Yes q No

Have you received Financial Aid previously? q Yes q No

Please name a person or persons in the U.S. we may contact in case of emergency:

Name: ________________________________________________________________________________

Relationship: __________________________ Phone: ________________________________________

Address: _____________________________________________________________ Zip: ____________

Work Phone: ____________________ Fax: ____________________ E-Mail: ____________________

Do we have your permission to contact them? q Yes q No

Do you have insurance coverage while abroad? q Yes q No

If yes:

Insurance Company: ____________________________________________________________________

Policy Number: ________________________________________________________________________

Policy Holder: _________________________________________________________________________

Do you have an International Student Identity Card? q Yes q No