<p> PWP Medellín, Colombia (USC-300 Summer 2015)</p><p>APPLICATION FOR PWP COLOMBIA 2015: DUE: 20 FEBRUARY 2015 Gender: M / F</p><p>Name of applicant: last first middle</p><p>DOB:: / / Place of birth: dd/mm/yyyy city state country</p><p>USCID#: ☐☐☐☐☐☐☐☐☐☐ First Language: Passport: Passport No: Passport Expiry: dd/mm/yyyy</p><p>School mailing address:</p><p> street apt/box no. city, state zip</p><p>Telephone: E-mail: </p><p>Permanent mailing address:</p><p> street apt/box no. city, state zip</p><p>Telephone: E-mail: </p><p>In case of emergency please notify:</p><p>Name: Relationship: </p><p> street apt/box no. city, state zip</p><p>Telephone: E-mail: </p><p>ACADEMIC INFORMATION:</p><p>Major(s): Minor(s): Graduation year: </p><p>Prior Spanish language learning experience (e.g., 3 yrs. Spanish in HS, SPAN-220): ______</p><p>Signature: Date PWP Medellín, Colombia (USC-300 Summer 2015)</p><p>NONREFUNDABLE COMMITMENT FEE AND WITHDRAWL ACKNOWLEDGEMENT</p><p>Due to the logistical complexities of the Conflict and Transformation: Colombia PWP (USC-300), only a small number of students can be permitted to register. If you are accepted for participation in the Conflict and Transformation: Colombia PWP (USC-300), you will be issued departmental clearance (D-clearance) to register for the course. Upon your registration in the course, your student account will be charged a commitment fee that holds your place in the class. At the end of the class session, this fee will be removed from your fee bill, provided you complete the course.</p><p>NONREFUNDABLE COMMITMENT FEE USC Dornsife academic programs that include travel collect a non-refundable $300 commitment fee from registrants in these programs. Since the Conflict and Transformation: Colombia PWP (USC-300) includes travel, students in USC- 300 have a commitment fee attached to their USC fee bill. This fee is due when you register for the class, but in no case later than the last day to register for this class.</p><p>WITHDRAWL ACKNOWLEDGEMENT</p><p>I, , acknowledge that I have read and understand the print name withdrawal and refund policy of my Dornsife special session program: Conflict and Transformation: Colombia PWP (USC-300). I understand that if I withdraw from this program, the strictest of applicable withdrawal refund policies (e.g., the policy with the greatest penalty) will apply.</p><p>Furthermore, I agree to a $300 charge to my USC student account. I understand that this commitment fee will not be refunded upon my withdrawal from the program, unless such withdrawal is completed in accordance with University policy before June 2, 2015. </p><p>Signature Date</p><p>Signature of legal guardian if student is under 18 years of age Date</p>