International Service Program Application 2013
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Full Name *
As it appears on your passport.
School *
Year *
E-mail *
Phone *
Birth Date *
Country of Citizenship *
Service Programs in order of preference *
(0 = cannot go, 1 = least interested in, 4 = most interested in)
0
1
2
3
4
Panama: May 24th - 31st
Panama: June 1st - 8th
Panama: August 9th - 16th
Panama: August 17th - 24th
Honduras: May 24th - 31st
Honduras: June 1st - 8th
Honduras: August 9th - 16th
Honduras: August 17th - 24th
Uganda: May 23rd - June 6th
Brazil: August 9th - 24th
Preferred Airport of Departure *
(use airport code)
Preferred Airport of Return *
(use airport code)
Spanish fluency *
Portuguese fluency *
Necessary for the Brazil trip
T-shirt size *
Do you have any dietary restrictions? *
Do you have any allergies or medical conditions? *
Emergency Contact Person Information
Full name *
E-mail Address *
Phone Number *
Time Zone *
Relationship *
Please answer the following questions below:
Will you be getting HIV testing and counseling training at the UAID Symposium in NYC this April? *
If you do not get trained at the symposium by UAID, then you will be responsible for getting certified in HIV testing and counseling individually prior to the trip.
Why do you want to be involved with UAID? *
(300 word limit)
How will you contribute to the group and the service program? *
Identify any previous travel, global health, or leadership experience you may have. (300 word limit)
Thank you!
UAID really appreciates your support and enthusiasm. We hope to see you on one of our international trip this summer! Please just electronically sign below to confirm that you filled out your application truthfully and to the best of your knowledge.
Name (Signature) + Date *
Submit
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