Name_________________Date of Birth ____/____/_____ Circle M F

Passport Number _________________Country of Issue ____________

Permanent Address_________________________________________

City/State_______________________________Zip________________

Country___________________________________________________

Present Address____________________________________________

City/State_______________Zip____________Country______________

Home Telephone (____) ____________Work Telephone (___)_______

e-mail address:____________________Fax #:____________________

If student:

College or University_____________________Degree goal__________

How did you find out about this program?_________________________

Enclose a paragraph essay about why you want to join the Lisle program and what you expect to accomplish by participating in this program.

Include a current photograph with this registration.

Do you need information on obtaining college credits for this program? It is an additional cost and additional paperwork. Yes____ No _____

Do you have any limiting medical conditions that we should be aware of? Please describe briefly. We will discuss with you the extent of special arrangements that can be made.

____________________________________________________________________________________________________________________________________________________________

Primary Language__________________Secondary Languages________________________

If English is not your primary language, do we need to be concerned about communication and make some additional arrangements to enrich your experience? Yes_____ No ______

Send application to Lisle Program Office as listed above with a registration fee of $250. If you have to cancel for any reason 8 weeks prior to the program, $200 of this fee is refundable. The balance of the program fee is due 6 weeks prior to the program although special payment arrangements are possible. Cancellation after 6 weeks prior to the program will result in a negotiated refund based on funds that have not already been committed to outside sources. We will attempt to facilitate airfares but Lisle assumes no obligation for payment or refund of travel costs to and from the host country.

Make checks payable to LISLE FELLOWSHIP INC. or pay by Mastercard or Visa:

Card# ______/_____/_____/_____ Expiration Date________ Signature____________________

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Signature of Participant___________________________________Date___________________

Signature of Parent___________________________________Date_______________________

(If participant is under 18 years of age, your parent (guardian) must sign)