Houghton, NY 14744

585/567-9453 or 567-9308

or paul.young@houghton.edu

APPLICATION FORM

The Houghton Down Under program offers a full semester of integrated study in cooperation with Kingsley College, a Wesleyan College of Bible and Theology, located in Melbourne, Victoria. The curriculum for this annual fall program is based in the Australian culture and uses the cosmopolitan urban setting of Melbourne to provide students with a unique learning experience. Admission to the program is by application only with priority given to students whose major fields will be best served by such an opportunity. Admission is competitively based on a minimum 2.75 GPA; purpose in going, and faculty recommendations.

PERSONAL INFORMATION

Full Name: _________________________________________M/F__________Age__________

Birth date__________ Citizenship__________Social Security #__________Passport #_________

Place of birth (City, state, country)__________________________________________________

Campus Address_________________________________Campus phone number_____________

Circle one: Married Single Divorced Other E-mail address__________________________

Parent’s Names_________________________________________________________________

Home address__________________________________________________________________

Home Phone ______________________________ Year in school (Circle one) 1 2 3 4

Ethnicity_____________________________ Religious affiliation___________________________

Have you participated in other Houghton off-campus programs? Yes No

If yes, which one(s)? ____________________________________________________________

Person to notify in an emergency___________________________________________________

Relationship_____________________________________ Phone ________________________

Address______________________________________________________________________

HEALTH INFORMATION

Health condition (Circle one) Excellent Good Fair Other–explain below

(e.g. asthma, diabetes, etc.)________________________________________________________

Any special dietary concerns? _______________________ Allergies?_______________________

Medical clearance: Are you willing to provide a physician’s clearance (form provided after acceptance) or permission to release college record? Yes No

Comments: ____________________________________________________________________

ACADEMIC INFORMATION

College:_____________________________Address___________________________________

Off-Campus Program Director____________________________________ Phone___________

Major(s)____________________________________ Minor(s)__________________________

Graduation date:_______________ Overall GPA____________ GPA in major______________

Are you open to a “home stay” living arrangement? Yes No

Do you require a “home stay” living arrangement (e.g. Inter-cultural studies) Yes No

After reviewing the description of the Houghton Down Under program, briefly describe your reasons for participating in the program and how your personal and academic goals would be enhanced by this experience. (Use extra sheet and attach to application)

Recommendation Forms: Two recommendations must be received for the application to be complete. One must be from your academic advisor; the other must be from a faculty/ministerial member who is able to evaluate your spiritual and emotional maturity, flexibility, motivation, academic and physical preparedness for overseas study. Please list these references below and deliver the forms to them

1. Advisor’s name__________________________________ Phone ______________________

2. Second name: ___________________________________ Phone _____________________

Procedure: Sign below that the information provided is accurate and send this completed form to: Dr. Paul Young, Houghton College, Houghton, NY 14744

Signed __________________________________________ Date_______________________