Alternative Break Trips Application Form

Please fill out the following form to apply for an Alternative Break Trip. Be as complete as possible with your answers.

"*" indicates required fields

Student Name*

First Name Last Name

Address*

Street Address City State / Province / Region ZIP / Postal Code

Email*

Phone*

Field of Study*

I am a ...*

Service Trip applying for*

Tell us why you would like to participate in this Service Trip?*

What do you want to take away from this experience?*

What part of the experience are you looking most forward to? Concerned about?*

Describe how your disability impacts your learning, any specific challenges.*

What are three things you can’t live without and why?*

Do you have any limitation to the kind of work you’re able to do?*

What role do you play when working in a group?*

This trip does require fundraising (group and individual). How do you plan on raising/acquiring the funds to meet your trip obligation?*

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Phone

This field is for validation purposes and should be left unchanged.

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