Name: MIT Undergraduate

2012 APPLICATION INTERCULTURAL EDUCATION IMMERSION Deadline: Thursday, April 21, 2011

Name: □ MIT □Undergraduate

Cell Phone: ( )______Permanent Phone: ( )______Email:[email protected]

Certification: □ Elementary □ Secondary PE Endorsement? □ Yes □ No If yes, do you need alt. level placement? □ Yes □ No Art Endorsement? □ Yes □ No If yes, do you need alt. level placement? □ Yes □ No Music Endorsement? □ Yes □ No If yes, do you need alt. level placement? □ Yes □ No ELL Endorsement? □ Yes □ No  yes  no

Major, Minor, and/or Areas of Endorsement: ______

Class standing as of Fall 2012: ______Advisor: ______

* Insert a digital photo of Directions: Write a paragraph response to each prompt below. This portion of the application yourself. Your student ID will be sent to your site. photo works well if you look professional. List your previous work experience with children:

Describe your past intercultural experiences:

Describe yourself in terms of responsibility, flexibility and how you get along with others: Return two copies of this page, the rest of the application, and the photo of yourself, to Kerry Templeton by Thursday, April 21st.

BIOGRAPHICAL:

Name ______D.O.B.______Sex: ____

SITE CHOICES: Please list your top preferences for your Jan Term placement. If one of your choices includes an international site, submit a copy of your passport with this application.

1.______3.______

2.______

If you selected a faculty-led trip, are you interested in being considered for a TA position? □ Yes □ No

ACADEMIC : (undergraduates only)

Cumulative GPA ______

My admission status to the School of Education is: □ Conditional □ Unconditional □ Not Admitted

MEDICAL HISTORY: Check the word which best describes your health: □Excellent □Good □ Fair □ Poor

List any past or current health issues, physical disabilities, and serious allergies:

______

Do you have any special needs, or require special services, during your program, (dietary considerations, learning aids or facilities with handicapped access.) Yes____ No____

If yes, please describe: ______

Are you required to take any medication: Yes _____ No _____

If yes, please give name of medication: ______

Please list any additional medication you are currently taking: ______Page 3 Page 4 2012 APPLICATION INTERCULTURAL EDUCATION IMMERSION Deadline: Thursday, April 21, 2011

PROFESSIONAL CONDUCT CODE FOR PARTICIPANTS

ALL STUDENTS MUST READ AND SIGN. The field experience in Intercultural Education has often been, for many students, the most significant field experience of their teacher preparation. In order for you to obtain the most from this experience, you should be aware of, and follow, the following professional guidelines:

Dress Appropriately You are representing yourself, Whitworth University and the teaching profession at your school site. Please dress appropriately. The first day you should dress very professionally; if you find that teachers are more casually dressed, ask your teacher and follow his/her cue. However, you should never wear jeans or sweats, unless you are changing for a PE class.

Conduct Your conduct will influence whether Whitworth University will be able to continue its Intercultural Program. Remember to follow campus policies and standards of student-teaching behavior while you are off campus. This is particularly important if you are the only student at a site. YOU are the person by whom school personnel will judge our program and university. We are fortunate to have this program; it is truly unique among universities.

Professional Boundaries As professionals you will be pleasant, friendly and caring with your students, but remember that you are an adult and a teacher who is a model – you need to establish and maintain appropriate professional boundaries with students. This means that you go to school-sponsored events, work with students concerning the school curriculum, and always work under the direction of your site teacher or administrator. This means that you DO NOT take students places in your car or meet students unsupervised outside of school. If you have concerns, requests or needs always contact your site teacher or administrator. You may also check with your Whitworth supervisor.

Work Ethic Arrive on time and stay for the full school day during the designated dates. Check with your teacher to find out when you should arrive and leave. Your teachers and principals will receive the information letter, description of our Intercultural Program, and a copy of the first page of your application. However, you may need to let them know if you have special abilities, needs or requests. Remember to be proactive, have a positive attitude, and thank folks for helping you. Remember that you are there as a guest of the school. Be a guest that they would love to see return!

I HAVE READ AND UNDERSTAND THE ABOVE GUIDELINES AND AGREE TO FOLLOW THEM:

Print name______

Signature: ______(both required)

Date ______

2012 APPLICATION INTERCULTURAL EDUCATION IMMERSION Deadline: Thursday, April 21, 2011

AGREEMENTS FOR PROGRAM PARTICIPANTS Please initial every box to acknowledge your agreement to the following program participant terms: FUNDS:  a. I understand that if my program balance is not paid in full 30 days prior to the start of the program I will not be allowed to participate and may forfeit monies paid.  b. If I have to withdraw from the program once I have begun payments I understand that I must consult with the Off-Campus Programs Office to see what portion is refundable, if any. FORMS:  a. I understand that I need to turn in a completed Travel Waiver and Consent Form to the Off- Campus Programs Office, by November 1, 2011.  b. If my paperwork is incomplete, I understand that my registration for my field experience course work will be cancelled. MEDICAL INSURANCE:  a. I understand that I must have medical insurance to participate in any off-campus program. RELEASE OF PERSONAL INFORMATION:  a. I hereby authorize the Registrar’s Office, the Business Office, Student Life and the Health and Counseling Center of Whitworth University to release information to the Intercultural Education  Program faculty that may be pertinent to my successful participation in this program. b. I understand that Whitworth University may talk to my cooperating teacher, parent(s)/spouse before or during the program for administrative, health or safety reasons. INDEPENDENT SITE PROPOSALS:  a. I understand that if my independent site placement proposal is turned down I will be placed in a Spokane area placement. INTERNATIONAL TRAVELERS:  a. If planning to go outside of the country, I understand that it is my responsibility to check www.state.gov for any travel warnings or announcements in the country that I am proposing for  my field experience. b. I understand that I will not be allowed to travel to countries that have current Travel Warnings in  place. c. I also understand that if this is an international program I will have to purchase an International Student Identification Card.  d. I understand that it is my responsibility to check for any health alerts at www.cdc.gov/travel/. It is my responsibility to get proper immunizations and medication before leaving. e. I have a current, valid U.S. passport and I’ve attached a copy of it to this application.

Please sign this form to indicate you have read, understand and accept the above terms of participation.

______Signature Date