Part I - Personal Information

Your Name:

Local Phone #:

Email Address:

Local / Campus Address:

Year of Graduation:

Major:

Age:

Foreign travel experience(s)?

Spanish Skill:

Fluent

Proficient

Beginner

None

Part II - Trip Information

This application form should be used to apply for either a Winter or Summer Break INTERNATIONAL SERVICE TRIP coordinated through Campus Ministry. Service trips vary based on the geographic location, length of trip, and type of service.

I wish to apply for an International Service Trip during the following University scheduled Break (select only one):

Winter Break

Summer Break

During the University Break that I selected, I wish to participate in the following trip:

Name of program:

Location of program:

Dates of Program:

Did you attend an Information Session about this trip?

Yes

No

Additional Comments / Program requests:

Part III - Previous / Current Community Service Involvement

Have you participated in a service trip (National or International) previously?

Yes

No

If yes:
When?

Where?

Program with which you worked:

List up to five (5) community service projects / programs in which you have participated within in the past two years.
Project / Program - Type of Service - Date(s)

Part IV - Health Information

How would you describe your general health?

Excellent

Good

Fair

Poor

Do you have health insurance coverage?

Yes

No

Do you have any health concerns that we should be aware of? If so, please explain (i.e. diabetes, heart problems, back problems, allergies, etc.) Medical clearance may be necessary.

Do you have any dietary restrictions? Please explain:

Part V - Self Reflection Short Answers

Please rank yourself in the following areas:

Willingness to accept responsibility

Excellent

Above Average

Average

Below Average

Weak

Unable to Judge


Ability to work collaboratively

Excellent

Above Average

Average

Below Average

Weak

Unable to Judge


Ability to set priorities

Excellent

Above Average

Average

Below Average

Weak

Unable to Judge


Ability to follow-through

Excellent

Above Average

Average

Below Average

Weak

Unable to Judge


Effective time management

Excellent

Above Average

Below Average

Weak

Unable to Judge


Maturity

Excellent

Above Average

Below Average

Weak

Unable to Judge


Initiative and Self Motivation

Excellent

Above Average

Below Average

Weak

Unable to Judge


Flexibility

Excellent

Above Average

Below Average

Weak

Unable to Judge


Awareness of social justice concerns

Excellent

Above Average

Below Average

Weak

Unable to Judge


Acceptance of differences

Excellent

Above Average

Below Average

Weak

Unable to Judge


Willingness to participate in group reflection and prayer experience

Excellent

Above Average

Below Average

Weak

Unable to Judge


Readiness for immersion in a developing country

Excellent

Above Average

Below Average

Weak

Unable to Judge


Sense of Humor

Excellent

Above Average

Below Average

Weak

Unable to Judge


Of the Previous/Current Community Service Programs you listed in Section III, please choose the one that has had the greatest impact on you; describe how you have been impacted and why the experience has been significant for you (up to 250 words).

Describe your motivation for participating in Campus Ministry’s International Service Trip Program (personal, academic, and/or spiritual) (up to 150 words):

Describe your involvement in a group setting (i.e. team, club, committee, class group, etc). What were the highlights of your involvement with this group? What were the challenges? Why?

What personal strengths/characteristics would you identify as potential assets to the group as well as to the persons you will serve?

What personal weaknesses would you identify as potential challenges to the group experience?

In what ways do you hope to grow as a result of your participation in the International Service Trip Program (academically, personally, spiritually)?

What, if anything, do you foresee as being a challenge for you to participate in this program ?

Participating in the International Service Trip Program involves a time commitment: Fundraising, Attendance at all pre-trip preparation meetings (typically 6-8 meetings; each is 2 hrs in length), Pre-Trip Community Building Retreat, Trip itself, Post-Trip meeting and follow-up. Considering your academic, extra-curricular, and work commitments, are you able to make this time commitment?

Yes

No

If No, please explain (up to 100 words):

Do you have any questions or concerns that you would like during the interview procces?

Please list the three (3) persons [Marywood faculty/staff, family member, peer] you have requested to complete a Recommendation Form on your behalf for this selection process.

Marywood University faculty/staff persons who know you well and that you have requested to complete a recommendation form for you:

Name:

Dept:

Family member who knows you well and that you have requested to complete a recommendation form for you:

Name:

Address:

Peer who knows you well and that you have requested to complete a recommendation form for you:

Name:

Address: