NATIONAL IMMERSION APPLICATION FORM | Pacific School of Religion

This application is to request your participation in PSR's Immersion Course during the upcoming Intersession.

The deadline for this application is October 1st.

A $150 deposit check is required to complete this application** (check payable to PSR).
This deposit is refundable if the application is not accepted.

Please note the name of the immersion course on your check, and send it to:

          Office of Contextual Learning
          Holbrook 125
          1798 Scenic Avenue, Berkeley, CA 94709

** If you are unable to provide a deposit of $150 before October 1st, please indicate this on your application form.

Course Title: *

Course Number:

CONTACT INFORMATION

Full Name: *

Address: *

School Email [xxx.edu]: *

Best contact number(s): *

GTU School of affiliation: *

Degree Program: *

IDENTIFICATION INFORMATION

This information is used to coordinate logistics. It is NOT used to determine eligibility.

Date of Birth:

Gender: *

Birthplace:

Citizenship: *

COURSE PARTICIPATION

Why do you want to participate in this immersion course?: *

What kinds of presentations, advocacy and other support work might you plan upon your return to PSR?: *

Time on the immersion trip will be limited and intense. How do you respond when under stress and confronted by important issues and deadlines?: *

How do you respond when living in community?: *

What is your understanding of the role of faith communities and religious leadership in political advocacy and public policy?: *

FINANCIAL AND MEDICAL SUPPORT

There are many sources you might explore for financial support, including personal savings/income, loans, grants, letters requesting personal sponsorship, PSR immersion funds, denominational and/or congregational support, and community group sponsorship/promise of presentations.

Are you able to send a deposit of $150 by October 1st?: *

Do you have health care insurance?: *

Is there any reason you would not be able to participate in any collective student fundraising efforts?: *

If you are unable to, please explain why this is so.:

Do you need to be considered for Financial Aid for this immersion course?: *

FINANCIAL AID INFORMATION

If you answered YES to the above question, please complete this section.

PSR will award financial aid to qualified applicants based upon the following criteria:
A. Total cost of the trip.
B. Financial need as reflected in the applicant's current year financial aid application.
C. Supplemental financial information provided below.

If you have not submitted an application to the GTU Financial Aid office, please complete a financial aid application and submit it to the Office of Contextual Learning (forms available on the GTU Financial Aid website)

1. Have you submitted the financial aid application for the currect academic year to the GTU Financial Aid office?:

2. If your financial condition has changed since you completed the GTU financial aid application, or if there are other financial factors which you would like the committee to be aware of, please include this information here:

3. If there are other factors you would like to have considered by the committee, please provide additional information here:

CONFIRMATION

I understand that I am not enrolled in this course until (a) my application is accepted, (b) I confirm my acceptance AND (c) I enroll in the course during early registration in November: *

YES

I understand that if this trip is cancelled, any monies already paid for trip expenses that are not refundable to PSR will not be refundable to me: *

YES

I understand that the pre-trip class sessions are a REQUIRED part of this immersion course and that I must attend them to be eligible for this course: *

YES