Application for Alternative Spring Break
Application for Alternative Spring Break


Global Community Engagement
1344 Coconut Dr.
Fort Myers, FL  33901
Phone: (239) 226-0817
Fax: (239) 226-0817
First Name:   
Last Name:
What school or organization are you with?:
Gender: MaleFemale
Street Address:
Apt/Bldg. Number:
City:
State:
Zip Code:
Email Address:
Daytime Phone Number:
Date of Birth:  (mm/dd/yyyy)
Citizenship:
Passport Expiration Date:  (mm/dd/yyyy)
Have you ever traveled or lived outside of the United States? YesNo
If yes, where and how long?:
Please check the box that best describes your SPOKEN language skills in Spanish FluentGoodSomeNone
Please check the box that best describes your SPOKEN language skills in Creole FluentGoodSomeNone
Please select the date range of the service project that you are applying to:
Emergency Contact Name:
Please enter in their full address and a phone number that they can be reached at in case of emergency.
By typing your name here you state that you have read and agree to the terms and conditions of this application: *

 

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