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Cultural Connections Travel Application
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Cultural Connections Travel Application
Name
*
First
Middle
Last
Cell Phone
*
MPTC Student Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Student ID Number
*
Date of Birth (must be age 18 or older)
*
MM slash DD slash YYYY
I am in good standing academically and with student conduct.
*
Yes
No
For international travel, do you have a passport?
*
Yes
Applied, but passport hasn't arrived yet.
I need help getting a passport.
For domestic travel, do you have a REAL-ID?
*
Yes - I have a current passport
Yes - I have a REAL-ID
I am working on or in process of obtaining a REAL-ID
I need help getting a REAL-ID
Degree program:
*
When do you plan to graduate?
*
MM slash DD slash YYYY
Are you a full- or part-time student?
*
full-time
part-time
What is your primary campus?
*
Beaver Dam
Fond du Lac
West Bend
Online
Which Cultural Connections experience do you wish to participate in?
*
Select one
Costa Rica - Spring Break 2022
New Mexico - Fall 2022
Spain - Spring 2023
New York City - Fall 2023
I have filed a FAFSA and met with a Financial Aid Specialist to plan for my funding and how to pay any outstanding balances for the Cultural Connections Travel.
*
Yes
My upcoming meeting is scheduled
No
I plan to take the Introduction to Diversity course.
*
Yes
No
I would like to apply for a Cultural Connections Scholarship to help fund my experience.
$250 (for U.S. Domestic travel)
$500 (for international travel)
Please check all that apply:
Veteran
Single parent
First-generation college student
I have other financial challenges (please explain below)
Please explain.
Personal Statement – in a minimum of 300 words, please tell us why you wish to participate in Cultural Connections? What do you wish to gain? How will this experience impact your future goals?
*
How did you hear about Cultural Connections?
*
Please list an MPTC faculty or staff reference who is familiar with your classroom behavior and college activities. The Student Community Impact Coordinator will contact this reference.
*
Additional Requirements
1. Color copy/scan of your passport or REAL-ID (for U.S. Domestic travel.) Please email to
alemke2@morainepark.edu
2. I will be required to sign an MPTC Cultural Connections Student Travel Code of Conduct.
By signing below I understand:
*
Please check all fields below.
I will receive an email to my MPTC student email notifying me of acceptance for Cultural Connections travel participation.
I will continue to receive and respond to emails to my MPTC student email for all Cultural Connections information and requirements.
I am required to attend all orientations. Students must make arrangements with instructors, work, childcare, etc. to attend orientations or risk being dropped from the program.
The College may disclose my information to the Study Abroad Association as the third party provider.
The College may disclose my information in emergency circumstances to a parent, guardian or third party provider; if necessary to protect my health, safety and property.
I understand I am participating in a College program and representing Moraine Park Technical College during my participation. I am expected to comply with the Student Code of Conduct found in the MPTC Student Handbook at all times.
I understand I will be in compliance with State of WI age 21 and above laws for alcohol consumption, no matter my travel destination. If I am of legal drinking age, my consumption will not interfere with any part of the scheduled program or negatively impact other participants. I understand many countries have strict penalties regarding drug use and possession. Individuals caught with even a small amount of an illegal substance may face heavy fines, arrest, or incarceration; as guests in the host country, Cultural Connections participants are subject to the local laws and punishments. Should an American be imprisoned overseas, the U.S. government cannot secure that person’s release or provide legal support. Likewise, Moraine Park is not responsible for legal counsel for a Cultural Connections participant accused of a crime. Any participants caught with illegal substances will be subject to program dismissal.
My past or pending student conduct issues will be taken into consideration and may prevent participation in Cultural Connections travel. Conduct issues that arise any time prior or during travel may risk being dropped from the program. Any financial loss incurred is my responsibility.
I will be required to sign an MPTC Student Travel Code of Conduct.
Financial payments must be submitted by the program deadlines. Any failure to meet these deadlines risks being dropped from the program. All payments are made online through the Study Abroad Association. All Cancellation and Refund deadlines apply. All payments are non-refundable unless the College cancels the travel experience up to 100 days prior to departure due to low enrollment.
Cultural Connections travel may be physically and mentally demanding. I may stand for lengthy times, sit for lengthy times, walk miles each day, travel on planes, trains, boats, and buses. I may participate in activities such as climbing stairs, hiking, rafting, snorkeling, and carrying luggage. Accessibility varies greatly from country to country and the Americans with Disabilities Act does not apply outside the U.S. MPTC strives to provide equitable learning activities for all Cultural Connections participants, including students with disabilities. To request an accommodation, or for inquiries about accessibility, please request an appointment with an Accommodation Specialist in MPTC Disability Resources through
Accommodate
or call 1-800-472-4554 with any questions or requests for accommodations.
I will be required to complete Study Abroad Association forms for medical disclosure and emergency contact information.
For domestic travel, I will be required to provide proof of my health insurance.
For international travel, I will be required to provide proof of my health insurance, and register for an international travel coverage policy provided at no additional charge.
I will be required to sign an MPTC Acceptance of Risk and Release of Liability Waiver.
Applicant Electronic Signature
*
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Last
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