Exit this survey

1. Contact and Basic Information

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Please complete all fields in this online application before the due date of February 10, 2016.

If you have technical problems with the survey, please contact Beth at 414-758-2280. If you have questions about the trip, please contact Antoinette Mensah at 414-758-2280

PAGE 1: PERSONAL INFORMATION:

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* 1. Please provide your contact information:

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* 2. What is your date of birth? (please use format MM/DD/YYYY)

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* 3. Do you have a valid passport? (Passport must not expire for at least 6 months after the return date of your trip.)

Please Note: You do not need to have a passport to apply for the program. However, you will need to have a passport as soon as possible as it is needed to book your flight.

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* 4. If you already have a valid passport, please enter the following information:

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* 5. Emergency Contact Person(s):
(at least one person's name and phone or e-mail address is required)

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* 6. Do you have any health or dietary restrictions?

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* 7. Do you speak any Spanish or Creole? (you can indicate your level in questions 7 & 8)

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* 8. If you speak Spanish, please indicate your level of proficiency:

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* 9. If you speak Creole, please indicate your level of proficiency:

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* 10. If you are a member of a parish, please enter the name and location of that parish:

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