STAC/Schools for Chiapas Application

CHOOSE APPLICATION TYPE AND DATE

Language School (mm/dd/yy) __/__/__ to __/__/__

OR

School Construction Team / Caravan

(Circle you choice)

July 25th 2004 - August 7th 2004

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PERSONAL DATA

First Name:

Last Name:

Telephone:

Address:

Address 2:

City:

State:

Zip:

Country: 

Email:

Passport Number:

Age:

Sex:  

Language Skills

English:  Fluent    Advanced    Intermediate    Basic    None

French :  Fluent    Advanced    Intermediate    Basic    None

Spanish: Fluent    Advanced    Intermediate    Basic    None

ESSAY SECTION (Please be brief!)

1. How did you hear about the work of STAC/Schools for Chiapas and why do you want to help out?

2. What are your primary goals of participating in this program?

3. How do you support causes in your own country.
Especially include the names and brief descriptions of any
social justice of environmental organizations that you belong to.

MEDICAL INFORMATION

Health Care Plan OR Insurance:

Telephone:

List all allergies to foods, drugs, or other items:

Are you under a doctor's care? (If so, please describe)

Do you take any form of drugs or medications? (If so, please describe)

Do you have any medical factors which might be aggravated by strenuous physical and/or psychological stresses at high altitudes under conditions of exposure to extreme heat and/or cold? (If so, please describe in detail)

CONTACTS AND REFERENCES

Non-governmental organization where you've
spent more than 150 hours in the last year:

Name of person who knows you:

Telephone:

Email:

Web site URL:

PERSONAL REFERENCE

Name:

Phone:

Address:

City:

State:

Zip:

Country:

Email:

EMERGENCY CONTACT

Name:

Phone:

Address:

City:

State:

Zip: