Summer Study Abroad - Jagiellonian, Krakow 2022

Kosciuszko Foundation Inc.

15 East 65th Street, New York, NY 10065

2022 Summer Study Abroad Programs

Jagiellonian University, Krakow Summer Programs

1 - Enrollment Details

Summer Session Programs (choose one) *

Session A, arrival Sunday, July 3 - return Sunday, July 31 Session C, arrival Sunday, July 3 - return Sunday, July 24 Session D, arrival Sunday, July 24 - return Sunday, August 14

Accommodations (choose one) *

Shared Room - no extra charge Single Room - extra charge

Which course(s) would you like to attend?

Please make sure that the courses you choose do not overlap and are taught during your stay in Kraków. The number of courses chosen does not affect the price of the entire program

9:00 a.m.-12:45 p.m. Polish Language (intensive) – taught on A, C, and D programs 2:30 p.m. - 4:15 p.m Polish Grammar, session I (ENG); July 5th-22nd, 30 hours 2:30 p.m. - 4:15 p.m. Literatura i kultura polska XX i XXI wieku (POL); July 5th-22nd, 30 hours 2:30 p.m. - 4:15 p.m. Literatura i kultura polska XX i XXI wieku (POL); August 1st-9th, 15 hours (PLEASE NOTE:on August 9th classes will be held untl 5:00 p.m.) 4:30 p.m. - 6:15 p.m.Contemporary Poland and Her Society (ENG); July 5th-22nd, 30 hours 4:30 p.m. - 6:15 p.m. Polish Grammar, session II (ENG); July 25th-August 3rd, 15 hours (PLEASE NOTE: fromJuly 25th to 29th classes will be held onsite, from August 1st to 3rd – online)

2 - Personal Information

Gender *

Male Female

Name *

First Name Last Name

Marital Status *

Single Married

Place of Birth *

USA Poland

Birth Month *

Month

Birth Date *

Date

Birth Year *

Year

Street Address (Home/Permanent) *

Street Address (include apartment #)

City *

City

State *

Current State

Zip Code *

Zip Code

Phone *

Phone number - Include spaces as shown: 212 734 2130

Personal E-mail *

Please list an e-mail address that you check frequently.

Your E-mail at School

E-mail at school - my name@school.edu

US Passport Number

US Passport #

US Passport Date of Expiration

US Passport - Date of Expiration

Polish Passport Number, if applicable

US Passport #

Polish Passport Date of Expiration

US Passport - Date of Expiration

Naturalization Certificate Number

See top right of Certificate of Naturalization.

Alien Registration # (Green card)

Alien Registration # (Green Card)

Date of Entry to the US

Date of entry to the USA.

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 Zip Code

Zip Code

Current Year of Study

Freshman Sophomore Junior Senior

Expected Graduation

Example: 06/2022

Expected Degree

Major

4 - Employer, if not in school

Name of Employer / Company

Employer / Company Address

Company City

Company State

Company Zip Code

5 - Purpose / Motivation

Why do you want to study Polish? *

Why do you want to study Polish?

Have you taken any courses in the Polish language? If so, list previous courses taken, level, text books, etc. *

List previous courses in the Polish language and texts used.

Speaking Polish *

None Poor Fair Good Excellent

Reading Polish *

None Poor Fair Good Excellent

Writing Polish *

None Poor Fair Good Excellent

List Other Foreign Languages You Know / Have Studied *

Other Foreign Languages

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

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

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

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 JU 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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