PCW Registration Form

Park Street Church, Boston USA Form Revision Date 5/10/2018

For Official Use ONLY T/Th

FRIENDSHIP MINISTRY TO INTERNATIONAL STUDENTS & SCHOLARS

Professional Communications Workshop Registration Form

INSTRUCTIONS: (1) Fill in GREY sections. Fill in dates as MM/DDYYYY (Ex: July 4, 1960 = 7/4/1960). Complete all items marked (*). (2) Save form and email to [email protected]. (3) Digital copies of your resumé and paper (or report) are due prior to first class.

ABOUT YOURSELF

FAMILY NAME * FIRST NAME *

GENDER * MALE FEMALE BIRTH DATE (Please tick one.) MM/DD/YYYY Click here to enter a date.

RELIGION ARE YOU MARRIED? * YES NO (Please tick one.)

HOME COUNTRY *

HOME COUNTRY ADDRESS (For temporary visa holders only.)

VISA TYPE * ARRIVED IN BOSTON ON * ex: J1, F2, B, H1b MM/DD/YYYY Click here to enter a date.

LEAVING BOSTON ON MM/DD/YYYY Click here to enter a date.

U.S. ADDRESS * Street Name

Apartment Number City Postal Zip Code

U.S. PHONE NUMBER * EMAIL ADDRESS *

EMPLOYER or SCHOOL * (Please fill in the name of University or Research Hospital or Company in the U.S.)

DEPARTMENT

DEGREE PROGRAM (If you are studying or working in a university or a research hospital, please fill in for example - B.A., M.A., Ph.D., post-doctoral, visiting scholar, etc.) ABOUT YOUR SPOUSE (Please leave this section empty if you are not married.)

FAMILY NAME * FIRST NAME *

EMPLOYER or SCHOOL * (Please fill in the name of University or Research Hospital or Company in the U.S.)

DEPARTMENT

DEGREE PROGRAM (If you are studying or working in a university or a research hospital, please fill in for example - B.A., M.A., Ph.D., post-doctoral, visiting scholar, etc.)

ABOUT YOUR FAMILY (Please leave this section empty if you do not have children.)

CHILD #1 FAMILY NAME *

GENDER * (Please tick one.)