United Planet Virtual Exchange Application Form - American-Iraqi Public Health Teams Addressing COVID-19 Project

Thank you for your interest in United Planet's Global Health Summer Program. Please complete the information below for all required fields. Your information will be kept confidential and only available to the review team and United Planet Program Administrators. Information collected is to ensure we are including people from a variety of backgrounds into the Program.

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* 1. First Name

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* 2. Last Name

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* 3. Your Address

Street address

City

State

Zip Code

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* 4. Gender

Female

Male

Prefer not to say

Other

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* 5. If you chose other for the question above, please specify

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* 6. Which Country do you currently live in?

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* 7. What best describe your ethnic origin?

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* 8. If you chose other for the question above, please specify

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* 9. Religion

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* 10. What will your grade/year be for the upcoming academic calendar year of 2020-2021

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* 11. Briefly describe why you are interested in this Cultural Virtual Exchange Program

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* 12. What are your learning goals for this Program?

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* 13. What is your native language?

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* 14. On a scale of 1 to 5, how prepared are you to working with people from different backgrounds, cultures, and countries as team?

Not At All Prepared

Less Prepared

Somewhat Prepared

Prepared

Well Prepared

Not At All Prepared

Less Prepared

Somewhat Prepared

Prepared

Well Prepared

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* 15. On a scale of 1 to 5, how inspired are you to working together with others to help solve challenges outside of your community?

Not At All Inspired

Less Inspired

Somewhat Inspired

Inspired

Very Inspired

Not At All Inspired

Less Inspired

Somewhat Inspired

Inspired

Very Inspired

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* 16. I am a (please choose):

University student /Team Captain

High school student