INCL 311 Application Form

(Submit to Chairman of Intercultural Studies Program as step 1 in formalizing the INCL 311 experience.)

Name  __________________________________________________________

Graduation Date  _________________________________________________

Major(s)   _______________________________________________________

Concentration and Minors   _________________________________________

Time of proposed Experience: [ ] Fall [ ] Spring [ ] Summer Date:

________________________________________________________________

Proposed place of experience:

[ ] Houghton semester abroad program. Specify ________________________

[ ] Other semester abroad program. Specify ___________________________

[ ] Internship abroad. Specify. ______________________________________

[ ] Other________________________________________________________

Language Requirement. Will you attempt to meet this during this Experience?
If so, state how:

________________________________________________________________

Name of likely On-Campus Mentor ____________________________________

Name and address/ email of likely On-Site Supervisor

________________________________________________________________

Comments:

 

Student Signature:   ____________________________________

Date:   ________________________________________
 

FOR OFFICIAL USE ONLY [ ] Application on file Date __________ [ ] Proposal approved Date __________ Initials _____________