Summer Study Abroad - Jagiellonian, Krakow 2020

3 - Current Education
Are you currently in school? *

Yes No
Name of School
Ex.: Regis High School Ex.: University of Colorado
School Address
Provide Complete School Address Information
School City
City
School State
School State
School Zip Code
Zip Code
Current Year of Study

Freshman Sophomore Junior Senior
Expected Graduation
Example: 06/2022
Expected Degree
Expected Degree
Major
Major

6- Emergency Contact Inforamtion
Name (Emergency Contact #1) *

First Name Last Name
Relationship to Applicant (Emergency Contact #1) *
Relationship to Applicant

Address (Emergency Contact #1) *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone # (Emergency Contact #1) *
Phone Number (Emergency Contact #1)
E-mail Address (Emergency Contact #1) *
E-mail address (Emergency Contact #1)
Name (Emergency Contact #2) *

First Name Last Name
Relationship to Applicant (Emergency Contact #2) *
Relationship to Applicant

Address (Emergency Contact #2) *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone # (Emergency Contact #2) *
Phone Number (Emergency Contact #2)
E-mail Address (Emergency Contact #2) *
E-mail Address (Emergency Contact #2)

7 - Emergency Contacts in Poland
Name (Emergency Contact in Poland)

First Name Last Name
Relationship to Applicant (Contact in Poland)
Relationship to Applicant

Address (Emergency Contact in Poland)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone # (Emergency Contact in Poland)
Phone Number (Emergency Contact #2)
E-mail Address (Emergency Contact in Poland)
E-mail Address (Emergency Contact #2)
Have you been abroad before? *

Yes No
If yes, list countries and purpose of visit
May we (the Kosciuszko Foundation) share your name and 3-mail address with other KF program applicants? If you respond yes, prior to the start of programs at JPII KUL you will receive a list of other KF program applicants who will be participating in the program. *

Yes No
The information I have supplied in this application is true. *

true
Signature - to append a signature please type in your full name *
Signature
Date *
Date
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