Personal Information:

First Name: Last Name: Date:

Phone Number: Email Address:

Home Address: Are you an American Citizen? Yes ( ) No ( )

List below any foreign countries you have visited:

Country Visited: Date and Length of Stay: Purpose of Visit:(Vacation, School, Volunteer, other?)

What leadership activities have you been a part of? What was your role?

What experiences have you had in America with paid or volunteer work experience with minorities, underprivileged people, the disenfranchised, and/or different cultural or ethnic groups?

Application for the University of North Carolina Wilmington

Peace Corps Preparatory Program

Please list below any languages spoken with conversational fluency:

Please list below any languages in which you can read and/or write with reasonable comprehension:

Academic Information:

Major (if declared): Minor (if declared): If not declared, what majors are you considering?:

How many hours completed towards degree?: Which semester are you currently in?

What is your current GPA?: Are you and American Citizen?What language courses have you taken so far or are currently enrolled in?:

Information Regarding Peace Corps Prep:

Why are you applying to this Peace Corps Prep Program?

If you were accepted into the Peace Corps, what part of the world would you want to be placed, and why?

How do you see this Peace Corps Prep Program preparing your for your career, regardless of whether you enroll in the Peace Corps or not?

Do you have any experience tutoring or teaching? Yes ( ) No ( )If yes please explain below:

Do you have, or plan on having, any experience with agriculture, forestry, construction, or another trade skill? If yes, please explain below: Yes ( ) No ( )

Do you have, or plan on having, experience in a healthcare related field/health education/health outreach? If yes, please explain below: Yes ( ) No ( )

In two pages or less, tell us what in your life has lead you to want to be a Peace Corps volunteer (double spaced, one inch margin, 12 pt. type). Attach to application.

Peace Corps Prep Program Application - UNCW

Release of Information

I permit the University of North Carolina Wilmington Peace Corps Prep Program to release information to the Peace Corps about the participants in this program. Understanding the UNCW Peace Corps Prep Program will detail information about my progress throughout the program and other information that will help the Peace Corps gauge the effectiveness of the PCPP. I understand these educational records are subject to the Family Education Rights and Privacy Act (FERPA). This act prohibits college officials from disclosing any records, including grade reports, academic standings, transcripts of records, or any other records which contain information directly related to the student and from which the student can be individually identified without my consent.

I hereby permit the University of North Carolina Wilmington PCPP to disclose personally identifiable information with the Peace Corps regarding my participation in the Peace Corps Preparatory Program for the purposes of assessing the PCPP. This information will be limited to my name, my date of admission to the PCPP, the course work and other activities I selected to satisfy PCPP requirements, date of graduation, and whether I successfully completed the PCPP upon graduation.

Student Name (Printed) ___________________________________________

Student Signature/Date ___________________________________________

Accepted by the director of the UNCW Peace Corps Prep Program:

Director Name ____________________________________________

Director Signature/Date _____________________________________