RESOURCE Foundation, Inc.

Rehabilitation, Education, Service, Opportunities, Retraining, Care, and Empowerment

1955 Rhettsbury Street, Carmel, IN 46032, U.S.A. Tel. & Fax: +1.317.258.6545

www.resourcefoundationinc.org

Instructions

Make a Copy

Keep a copy of all forms you submit to us.

Financial Information

We plan two Ukraine trips in 2010. The first is from May 12 to May 21, 2010. The land travel cost for this trip will be $1000. This will cover accommodations, meals, and transportation within Ukraine. Participants will need to arrange for their own air transportation to and from Kiev. The second Ukraine trip is scheduled for September 10 to September 26, 2010. The land travel cost for this trip will be $1500. The land travel cost will cover accommodations, meals, and transportation within Ukraine. Participants will need to arrange for their own air transportation to and from Kiev.

All flights MUST be coordinated with RESOURCE Foundation Inc. BEFORE making a final booking.

Program Fee Coverage

Our Web site provides full information on the fees for each program and the services included in our fees. Program fees cover housing, meals, in country travel, transfer and luggage handling and selected cultural events.

Exchange Rates

Our fees are set in U.S. dollars and do not change because of changes in the exchange rates.We use forward contracts to balance out the exchange rate fluctuations, which can result in an average exchange rate that may vary significantly from the daily rates quoted by banks.

Participant Information

Full Legal Name :

First Name

Middle Name

Last Name

Nickname or preferred name

Social Security Number

Passport Number

Country of Issue

Date of Birth:

Month

Day

Year

Citizenship

Gender:

School/Work Affiliation

Your Personal Mailing Address ( Students please indicate your address when school Is in session)

Street

City

State/Province

Zip/Postal Code

Cell Phone

Telephone

E-mail

School Ends

Your Home Address ( students, please indicate a permanent address)

Street

City

State/Province

Zip/Postal Code

Country (if outside the U.S.)

Telephone

Program Selection

Indicate below the program you are interested in attending.

Program

Dates:

Alternate Dates:

Whom should we notify in case of emergency?

Name

Street

City

State/Province

Zip/Postal Code

Country (if outside the U.S.)

Home Phone

Business Phone

Cell Phone

E-mail

Name

Street

City

State/Province

Zip/Postal Code

Country (if outside the U.S.)

Home Phone

Business Phone

Cell Phone

E-mail

About You

Have you traveled or studied abroad before? Yes No. If so, where?

Describe yourself

Describe your personal interests (hobbies, sporting activities, etc.)

What do you hope to achieve during this experience?

Do you have any special skills or training, beyond your basic professional experience, that may be particular help ?

Do you speak any languages other than English? Yes No. If so, what language(s) do you speak?

Is there anything else that you would like to share with the Foundation regarding your interest or expertise?

Please print out your application then submit it and appropriate payment to:

RESOURCE Foundation Inc.

1955 Rhettsbury Street

Carmel, IN 46032, U.S.A.

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