Chatham Maymester 2015 Faculty Led Field Experience Application
Applications must be complete and submitted by 4 PM on Tuesday, October 21, 2014.

If you are accepted and agree to participate in a Maymester 2015 Field Experience you also agree to 1) enroll in the corresponding spring 2015 prerequiste course; 2) initial, sign and return the Contract for 2015 Field Experiences to the Office of International Affairs by 4 pm on November 4, 2014; and 3) submit your $100 nonrefundable deposit to OIA by 4 pm on November 4, 2014.

Each Maymester 2015 Faculty Led Field Experience must meet its minimum enrollment number or it will be cancelled.

Questions? Please contact the Office of International Affairs, internationalaffairs@chatham.edu or 412-365-1388. Please direct questions regarding specific field experiences to the faculty leader(s).
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First Name *
Last Name *
Chatham student ID number *
Local address 1 *
Local address 2
City, state, zip code *
Local phone number *
Chatham email address *
Students Last name *
Non-Chatham email address *
Program Information
Due to minimum and maximum enrollment numbers, students may not be offered their first choice program.
Which program are you applying for? *
Please describe in 100-150 words, your motivation for applying to this field experience
Do you have second choice? *
Please indicate your second choice below.
Academic Information
What is your current academic status at Chatham? *
Number of undergraduate credits completed as of summer 2014 *
Number of credits completed at Chatham as of summer 2014 *
What is your GPA? *
Minimum GPA required is 2.0
What is your major? *
Have you already participated in a Chatham Maymester abroad? *
If yes, which program and which year?
Travel Document Information
Field experience participants are responsible for obtaining a passport by January 16, 2015 and any necessary visas prior to travel. The Office of International Affairs does not process or issue travel visas for students. All travelers should check the embassy web page of the countries they plan to visit for updated visa and travel requirements.
What is your country of citizenship? *
Do you have a valid passport? *
Your passport must be valid for travel until at least 11/15/2015. All students are required to submit a copy of their valid passport to the Office of International Affairs. If you do not currently have a valid passport, upon acceptance to a Chatham field experience, you are required to apply for a passport and submit your passport copy not later than 1/16/2015.
Emergency Contacts
Your emergency contacts must be able to act on your behalf in case of your incapacitation.
First Emergency Contact
Last name *
First name *
Relationship to you *
This must be a parent, spouse, child over 18 or legal guardian who is able to make decisions on your behalf in the event of an emergency.
Address - Street, City, State, Zip, Country *
Phone number with area code *
Please indicate the type of phone number *
Email address *
Second Emergency Contact
Last name *
First name *
Relationship to you *
This must be a parent, spouse, child over 18 or legal guardian who is able to make decisions on your behalf in the event of an emergency.
Address - street, city, state, zip, country *
phone number with area code *
Please indicate the type of phone number *
Email address *
Medical Information
Please fill out this form completely.

Maymester field experiences have varying levels of physical and cultural activities and requirements. If you have questions about a particular field experience, please contact the program leader.

Although this information is confidential and does not affect your candidacy for a Chatham Field Experience, Chatham University has the right to ask for further clarification of condition and/or proof of physical fitness for participation in a Maymester Field Experience.

Please note that some travel destinations require immunizations. Please visit the Center for Disease Control (CDC) at http://wwwnc.cdc.gov/travel or the Allegheny County Health Department at http://www.achd.net/infectd/travel.php for recommendations on immunizations and/or medications for travel.
Please list any medications you will be taking during the program abroad and what condition they are treating: *
If not applicable, type N/A
Please list any allergies you have: *
If not applicable, type N/A.
Please describe any medical conditions or other circumstances which the program leader(s) need to know about before acting on your behalf in an emergency: *
If not applicable, type N/A.
What is your blood type?
While it is recommended that you know your blood type, providing this information is optional.
Health insurance information
Please check your health insurance policy to see what coverage it provides for medical services abroad. See whether your plan pays the provider in the host country directly or if you must pay yourself and seek reimbursement later.
Health insurance provider name: *
Insurance policy identification number: *
Insurance policy provider web site address: *
Provider address, city, state, zip *
Provider phone number *
Any other issues or needs to share?
If yes, please share here:
Student Affirmation
By signing below, you agree that you have read and understood the guidelines regarding Chatham University Maymester 2015 Faculty Led Field Experiences and that all information you have provided is correct to the best of your knowledge. If you are accepted and you agree to participate in a Chatham Maymester 2015 Field Experience, you:

1. Agree to attend all mandatory predeparture orientations held by the program leader(s) and Chatham's Office of International Affairs;
2. Agree to adhere to all program rules and safety measures as outlined by your program leader(s) and Chatham's Office of International Affairs; and
3. Will be held accountable to the Chatham Honor Code, to all current Chatham academic regulations and to graduation requirements as outlined in the appropriate catalog(s).
Student signature *
Your mark below constitutes a signature agreeing to the above Student Affirmation.
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