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                  TICCS FIELD EDUCATION PROGRAMS
                                   APPLICATION FORM
                            For all Field Education Programs (SIA, FEP)


1. Personal Information: (Please Print or Type)

        Name:

        Street address:

        Box number:

        Home phone/fax:

        Office phone/fax:

        Email:


2. Personal Background:

        Date of Birth:

        Place of Birth:

        Citizenship:

        Passport No.:

        Occupation:

        Education level: B.A/S (    ), M.A/S.(    ), PhD. (   )


3. Please list the Colleges, Universities, Seminaries you’ve attended with your degree(s), major
fields studied, and the dates:

4. Briefly describe any previous studies/experiences of African culture, or of any culture other
than your own, through travel, workshops, seminars or formal academic programs:

5. Proof of English competency if English is not your first language (toefl score or support letter
from a qualified professor):

6. Besides English what other languages do you speak? Give your FSI rating in each.


7. What program are you applying for?

        Summer in Africa (SIA): (nine-weeks)                                (   )
        Ministerial Field Education Program (MFEP) (one-year)               (   )
        Interdisciplinary Field Education Program (IFEP) (one-year)         (   )


8. Do you have a special interest in any particular ethnic group in Ghana?
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9. Are you currently enrolled in a graduate program? How do you see the TICCS program fitting
into your training or career?


10. Will you be taking the TICCS program for credit?


11. How did you find out about the program?


12. Who is paying for the course?
       Personal responsibility             (   )
       Organization’s responsibility       (   )

                         Cash           (      )
                         Check          (      )
                         Money transfer (      )


13. Name and address of your sponsoring organization (if applicable):


14. Letter of financial support from the sponsor (if applicable).


15. Application fee: 250 USD
        Receipt of the application fee by 1 April.
        Make check out to: “Divine Word Missionaries” (write “TICCS Program” in the “memo”)
        Indicate in the note accompanying the check that the money is for your TICCS course.
        Send the check and letter to:

        Attn. Fr. Thomas Krosnicki SVD
        Mission Office
        Divine Word Missionaries
        1835 Waukegan Road
        Techny IL 60082-6099 USA


16. Payment for the program: The application fee is credited toward the full payment for the
course. Full-payment is required by the beginning of the course.
        (Same process of payment as for the application fee)


17. Statement from a Medical doctor testifying to the fitness of the applicant:


18. Proof of healthcare insurance.


19. For FEP and ATP applicants: Formal letter of application to TICCS with copies to Ghana
Immigration Services stating that you wish to undertake a graduate course at Tamale Institute of
Cross-Cultural Studies for a period of one year dated not later than 1 April.


20. Two letters of recommendation from any of the following:
       Clergymen (necessary for MFEP applicants)
       Teacher/Professor
       Counselor
       Employer
       Medical Doctor
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21. Person to contact in case of emergency:
        Name:
        Address:
        Phone No.:
        Fax No.
        Email:


22. Write a short essay of 500 words describing what you hope to gain from this program:


23. Statement of Waver (for insurance purposes):

I agree to hold the Society of the Divine Word and the Archdiocese of Tamale and their
representatives harmless of any and all liability that may arise in connection with my participation
in the programs of Tamale Institute of Cross-Cultural Studies, Tamale, Ghana.


24. Agreement with the Course Requirements:

(   ) I HAVE READ AND UNDERSTAND THE COURSE REQUIREMENTS

(   ) I AGREE TO COMPLY WITH THESE REQUIREMENTS.


25. Signature:                                    Date:



SUMMARY CHECKLIST OF ITEMS TO BE SENT:
This official form (by post or email)
Letter from a school official
Proof of English competency
First letter of personal recommendation
Second letter of personal recommendation
Doctor’s letter
Proof of Health Insurance Policy (e.g. a pay-slip or statement)
Application fee of 250 USD (Before beginning the course the remaining 4,750 USD)
Letter of Application to TICCS by April 1
Agreement with Course Requirements

				
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