PANTHER PROGRAM APPLICATION

PANTHER PROGRAM APPLICATION School of Social Work 2117 Cathedral of Learning Pittsburgh, PA 15260 412-624-6300 - phone Center on Race and Social Problems 2001 Cathedral of Learning Pittsburgh, PA 15260 412-624-7382 - phone crsp@pitt.edu Study Abroad Office 802 William Pitt Union Pittsburgh, PA 15260 412-648-7413 - phone 412-383-7166 – fax abroad@pitt.edu University of Pittsburgh University Center for International Studies Application for Cuban Social Policy Issues 2010 Dates of the Program: Depart Pittsburgh: 5 March 2010 Arrive Havana: 6 March 2010 Depart Havana/Arrive Pittsburgh: 14 March 2010 Note: The final deadline for this application is 6 November 2009. Applications are received and students may be accepted on a rolling admission basis. If you are planning to participate, please apply as early as possible to secure your slot in the program. Return Application Material to 802 WPU. Please submit the following items to the Study Abroad Office – 802 WPU APPLICATION CHECKLIST _____ Part 1 – APPLICATION (Pages 3 and 4 of this document) _____ 1. One official transcript from all universities where you have earned 15 or more credits. (Your transcript must include grades from the most recently completed term at the time of the deadline) _____ 2. A one-page essay articulating your learning objectives for participating in this study abroad program. _____ 3. Academic Reference - This letter must be from a professor who has taught you in class. You should collect the letter from your professor in a sealed and signed envelope as part of your application. _____ Part 2 – DISCIPLINARY CLEARANCE FORM It is your responsibility to submit this form to the Assistant Dean of Students Office at least two weeks before the program application deadline. Clearance forms must be valid for the current term at the time of the application deadline. The Assistant Dean of Students Office will return this form to our office. Pitt students submit this form to 738 William Pitt Union. Only COMPLETE APPLICATIONS will be reviewed. It is the student’s responsibility to collect and submit a complete application packet. The only form that will be forwarded to Residence Life separately is the Disciplinary Clearance Form. All applications will be reviewed by the Admissions Committee. Cuban Social Policy Issues Program Application Page 2 of 6 PART 1 – APPLICATION Please enter all information completely and legibly by typing or printing in ink. Name: Mr. Ms. PeopleSoft ID: (last) (first) (middle) Program for which you are applying: Cuban Social Policy Issues Current Address: Valid until: ____-____-______ Permanent Address: Telephone: Pitt Email: Other Email: Permanent Phone: Cell Phone: Gender: Ethnicity: (optional) Male Female African American Hispanic American Date of Birth: Caucasian Native American Asian / Pacific Islander Other: PASSPORT NUMBER: US Passport? (If no, please list your country of citizenship: Expiration Date: _______-_______ ) (If you do not have a passport, you may still apply for a Study Abroad program, but you should apply for one immediately.) Graduate School: QPA: Expected Graduation Date _____-_____ Have you ever studied or traveled abroad? _____ If “YES”, when, where, why and for how long? Cuban Social Policy Issues Program Application Page 3 of 6 What languages have you studied at the college level? Please list all languages (not just ones for country of planned study) and how long you have studied them: List any courses you have taken about the country or region of intended study: List all of the courses you are currently taking as they will not be listed on your transcript: The answers I have given are correct to the best of my knowledge: ____ (Signature of Student) __________________ (Date) By initialing here ______, I understand that pending acceptance; students will be required to attend at least three orientations/programs prior to the trip. Dates will be provided via e-mail. Cuban Social Policy Issues Program Application Page 4 of 6 PART 4 – Panther Program: DISCIPLINARY CLEARANCE FORM Please fill in all information completely by typing or printing in ink. You must drop off this form to the appropriate office at least two weeks before the stated application deadline. The Assistant Dean of Students Office will return this form to the Residence Life Office. To the Student: This form must be completed by the Assistant Dean of Students, who is located in 738 William Pitt Union. Your signature provides consent for release of this information. Name of Student: Social Security Number: _____-____-_____ Phone: School or College (i.e. ARTSC, ENG, CBA, Penn State, etc.): PITT-DEVELOPED PROGRAM: Signature: To the Judicial Affairs Office: The student named above has applied to participate in a University of Pittsburgh sponsored study abroad program. We would appreciate a confidential statement evaluating this student’s record at your institution. While a prior disciplinary history does not preclude a student’s participation in our program, this information is taken into consideration during review and must be submitted in order for the student to be evaluated for admission to the program. The return of this form at your earliest convenience will expedite the student’s admission status. Cuban Social Policy Issues Application Deadline: 6 November 2009 (students will be accepted on a rolling admission basis until this date) Date: Email: This student has not received a judicial sanction at this institution. This student is not currently not under active judicial sanction, but has been sanctioned previously (please use space below to elaborate) This student is currently under judicial sanction (please use the space below to elaborate) ____________________________________________________________________________________________________________ Active (Yes / No) Adjudication Date Brief Description of Offense ________________________________________________________________________________________________________ Sanction(s) with Effective Dates ________ Active (Yes / No) Adjudication Date Brief Description of Offense _____________________________________________________________________________________________________________ Sanction(s) with Effective Dates __________ Active (Yes / No) Adjudication Date Brief Description of Offense ________________________________________________________________________________________________________ Sanction(s) with Effective Dates PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM. Cuban Social Policy Issues Program Application Page 5 of 6 Additional Comments (please indicate whether or not any sanctions above should prevent this student from studying abroad): Name: Title: Institution: Telephone: Signature: __________________________________________ Date: _______ Please fax or mail to: Panther Program Advisor University of Pittsburgh Study Abroad Office 802 William Pitt Union Pittsburgh, PA 15260 Phone: 412-648-7413 Fax: 412-383-7166 Cuban Social Policy Issues Program Application Page 6 of 6