Application Form

First Name

Middle Name

Last Name

Nickname (if you have one)

Date of Birth

Gender

Male

Female

Primary Email

Secondary Email

Home Phone

Mobile Phone

Country(ies) of Citizenship

Place of Birth

Passport

I do have a US passport valid 6 months after the summer school program ends

I do not have a US passport valid 6 months after the summer school program ends

Current GPA

Current Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Please list carefully any illnesses, allergies or conditions (physical or mental). Pre-existing medical conditions not listed in your application, which become evident later, may result in the rejection of your application with no refund, or your early termination and dismissal at your expense.

If you answer “yes” to the following, it does not mean you will not get to go. We just need to know.

Do you snore?

Do you sleepwalk?

Please use this field to elaborate on anything in this part of the application

Parent/Guardian #1

First Name

Middle Name

Last Name

Relationship to Student

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Home Phone

Mobile Phone

Work Phone

Parent/Guardian #2

First Name

Middle Name

Last Name

Relationship to Student

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Home Phone

Mobile Phone

Home Phone

Language Experience— Classes are conducted in English, so this will not affect your application and is for our information. Indicate your ability (if any) in languages other than English.

Please:

Indicate language(s)

Speaking ability – Rudimentary, Functional, or Conversant

Comprehension – Rudimentary, Functional, or Conversant

Years studied

Languages

Student Disclosure and Approval of Participation to be completed by applicant:

Please review the following statements very carefully, select each checkbox to indicate your agreement, and sign at the bottom of this section.

I understand that I am expected to participate fully in all program lectures and activities while enrolled in Live and Learn in France, regardless of whether my home institution will be providing credit for the program. I understand that if I do not participate fully, I may be required to leave the program.

I certify that the information disclosed in this application is true to the best of my knowledge.

I consent to have Live and Learn store my submitted information so they can respond to my application.

Date

Electronic Signature (Full Name of Student)

Application Checklist

Prior to sending in your application, please double-check that you have completed the following components:

Application
$200 non-refundable application fee*
*This will be refunded in the event that your application is not accepted

You may pay by electronic means (Zelle, Venmo) – use [email protected]. Make sure it’s clear who it’s from.

BE SURE TO SELECT “PAY FRIENDS OR FAMILY” OTHERWISE YOU MAY HAVE TO PAY A FEE.

If your application is successful, there will be a couple more forms to submit before final acceptance.