Application for Childhood Development in an International Setting Class

Personal Information:

Name:
Address:
City:
State:
Zip Code:
Telephone:

Status at Misericordia

Pediatric Certificate Alumnus
Pediatric Certificate Current student
Post Professional Masters Alumnus
Entry Level Masters Alumnus

Current Student

OTD
Post Professional Masters
Pediatric Certificate
Entry Level Masters

Years of Experience in Occupational Therapy

Student entry level
Pediatrics List years
Adults List years

Employment Experience Please enter name and venue of health care related employment within the last 3 years

Current Employer
Dates of Employment Type of Setting
Previous Employer
Dates of Employment Type of Setting

Passport Status

I have a current passport, with experation date at least six months after planned return.

Date of expiration Copy of active passport must be provided with deposit

I do not have a current passport, but have begun the application process.
I do not have a current passport, and have not initiated the application process.

Brief Essay-in two-three paragraphs, please briefly explain to us your desire to participate in this course, what you think you will gain professionally and personally, and what your strengths are as they would support participation in this course.


Travel Experience-Travel experience outside of the United States is preferred but not mandatory. Please list below any relevant travel experiences, including reason for travel, location, and approximate length of stay. List only experiences which may apply to this trip.