CYMA

2008 CYMA Pilgrimage Application

Please fill out the following form. All fields must be complete for the application to be considered. Failure to fill out all fields correctly will require resubmission.

Personal Information

First Name: Last Name:

Address: City: State: Zip:

Tel: Fax: E-mail:

Gender: Date of Birth: Ex: YYYY-MM-DDCountry of Birth: Citizenship If other, where?

I Have a Passport Passport Number Passport Exp. Date Ex: YYYY-MM-DD Name on Passport Please write your name exactly as it appears on your passport

Emergency Information

First Name: Last Name:

Address: City: State: Zip:

Tel: Fax: E-mail:

Parent Information This information is the same as my emergancy contact

First Name: Last Name:

Address: City: State: Zip:

Tel: Fax: E-mail:

Medical Information Do you have any medical conditions including allergies? (please list) Are you on any medicaton? (please list) Will you need any special care while in Armenia (please explain)

Education

Institution Name: Dates Attended: Degree Obtained: Location: Major:

Armenia Have you taken any Armenian Studies Courses or attended Armenian School? (Please list.)

Do you speak, read, or write Armenian Speak Read Write Dialect What other languages do you speak: How did you hear about CYMA:

The Essay

Spending two weeks in our Homeland is sure to bring you many new experiences that will change your life. What are your expectations for this spiritual pilgrimage and what aspects are you looking forward to the most?

Please have your essay ready for submission with proper grammar and spelling as they will be read by CYMA executive members and the CYMA coordinator. Essays must be at least one typed double spaced page for consideration.

Response

Agreement

I consent to the following:

CYMA accepts no responsibility for costs arising from accidents and/or illness incurred during my internship. I undertake the following obligations:

Adhere to all policies and procedures set by CYMA
To refrain from any conduct that would adversely reflect on CYMA or the institution I will be assigned to

Upon submitting my application, I will send a deposit of $1000, only to be cashed by CYMA upon my acceptance to the program.
I will render my final payment by the deadline determined by the CYMA Executive Commiittee

I AGREE TO THE ABOVE STATEMENT