Ukrainian Autumn Application Form
Student information:
First Name: *
Family Name: *
Gender:
Birthdate: *
MM
/
DD
/
YYYY
Phone number: *
(if you have Ukrainian number please write it also)
Email: *
Nationality: *
Mailing Address:
Street and house number: *
City: *
State/Province/Territory: *
Postal Code/Zip: *
Country: *
Give the names and addresses/phones of relatives or friends, who may be contacted in case of an emergency: *
In your home country and in Ukraine:
Occupation and educational background:
If you're currently a student, what School/ University do you attend?
(Name and address of your school, year you are in now)
What languages other then English do you know?
Do you have any previous experience in learning Ukrainian? *
If possible please write which materials you used.
What is your proficiency level in Ukrainian? *
No proficiency
Beginner
Intermediate
Advanced
Superior
Speaking
Writing
Reading
Program details (dates, cost etc.)
Which session do you choose? *
Required
Required
Do you or member of your family have experience in participating any program at School of Ukrainian language and culture?
(Those who are will receive a 10% discount for tuition)
Would you like to take course for credit? *
Required
Write your University registrar's office address:
(For those, who needs credits or where you would like your transcript to be sent)
Write a paragraph to describe your interest in the Summer Program in Ukraine: *
How did you learn about our Summer Program? *
State of health *
(please indicate any special needs related to health concerns, i.e., medical conditions and/or medication, wheelchair, crutches, diabetic, allergies: food, medical or enviromental, etc.)
*
Required
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