IMMERSION COURSE APPLICATION FORM RETURN THIS APPLICATION and a $50 - $150 DEPOSIT CHECK** payable to PSR Deposit is refundable if application is not accepted Please note the name of the immersion course on your check TO: Community Engaged Learning Pacific School of Religion Holbrook 125 1798 Scenic Avenue, Berkeley, CA 94709 CEL@psr.edu ** If you are unable to provide a deposit, please indicate this in the Financial Support section of this application. If you are hand-writing this application, PLEASE WRITE LEGIBLY. Use extra paper if needed to complete your answers. Course Title / Faculty: CONTACT INFORMATION Preferred Name: Gender Identity: For Roommate Coordination Course Number: International Students, please check here: Preferred Gender Identity of Roommate(s) Address: Please provide information exactly as it appears on your Passport or State ID. This information is used to coordinate logistics, such as airline tickets; it is not used to determine eligibility. Legal Name: Cell: Email Address: GTU School affiliation: IDENTIFICATION INFORMATION Degree Program: Sex: Date of Birth: Following is for international / border-crossing immersions only Birthplace: Citizenship: Passport Expires on: (REV 10/17) Page 1 of 5
COURSE PARTICIPATION These are the foundational Learning Outcomes for all immersion courses Students participating in a Contextual/Cross Cultural immersion course will be able to: Reflect on their social location for critical social analysis and theological construction that takes seriously context and partnerships with communities. Articulate how this immersion contributes to one s formation as a leader in spiritual and social transformation in one s future context in ministry / service. Identify the systemic issues that interconnect the global and local contexts for ministry / service. Demonstrate cross-cultural theological understanding on issues of justice. Please reflect on these learning outcomes when formulating your responses. (1) Why do you want to participate in this specific immersion intensive? (2) How do you expect this experience to challenge your social location and current perspectives? (3) What kinds of presentations, advocacy and other ongoing change work are you willing to engage in or implement upon your return to PSR? PSR Community Engaged Learning Immersion Application Form (REV 10/17) Page 2 of 5
(4) Time and itinerary on the immersion trip will be full and intense. How do you respond when under stress and confronted by collective issues and deadlines? Give an example of how other participants in a group have/would describe you when you are under stress. (5) How do you respond when living in community on a learning journey with a class? Give an example. (6) What is your understanding of the role of spiritual and religious leadership in political advocacy and public policy? PSR Community Engaged Learning Immersion Application Form (REV 10/17) Page 3 of 5
FINANCIAL AND MEDICAL SUPPORT Beyond PSR Immersion Needs-based Financial Support, there are many sources you can also explore for financial support, including: personal savings/income, loans, grants, letters for sponsorship, denominational and/or congregational support, community group sponsorship via promise of presentations, and online fundraising campaigns such as Network for Good, etc. Are you able to submit a $50 - $150 deposit? If yes, indicate deposit amount NO Do you have health care insurance that will be valid for the duration of the trip?... NO Do you need to be considered for financial support for this immersion course?... NO Immersion Fund Financial Support is only available to PSR students who have never received immersion support funds Is there any reason you would not be able to participate in collective student fundraising efforts? (Please go to tinyurl.com/2017-parkingfund to volunteer)... NO If you are unable to participate in fundraising efforts, please explain why not: If you answered YES to the financial support question, please complete the following questions. Otherwise, proceed to Confirmation FINANCIAL SUPPORT INFORMATION PSR will provide Immersion Needs-based Financial Support to qualified applicants based upon the following criteria: A. Total cost of the trip, B. Needs-based support needed as reflected in the applicant s current year financial aid application, C. Supplemental financial information provided below, D. Number of students needing financial support. Have you submitted the financial aid application for the current academic year to PSR Financial Aid Office?... NO I give Community Engaged Learning staff permission to get my basic financial needs status from the PSR Financial Aid officer (Basic status = High need, Moderate need, Low need) Signature Date: If your financial condition has changed since you completed the PSR financial aid application, or if there are other financial factors to be considered, please include the information here: PSR Community Engaged Learning Immersion Application Form (REV 10/17) Page 4 of 5
CONFIRMATION By signing this application, I acknowledge that: 1. I understand that I am not enrolled in this course until (a) my application is accepted, (b) I confirm my acceptance, AND (c) I enroll in the course (usually during early registration.)... 2. I understand that my participation in this course will require that I sign a Waiver form (will be provided with acceptance letter.)... 3. I understand that if this trip is cancelled, any monies already paid for trip expenses that are not refundable to PSR will not be refundable to me.... 4. I understand that the pre-trip class sessions are a REQUIRED part of this immersion course and that I must attend them to be eligible for this course. Any exceptions to attendance must have approval from Course Faculty and Director of Community Engaged Learning 5. I understand that if I wish this course to meet the M.Div. Cross-Cultural Immersion Course requirement*, I must get approval from the Director of Community Engaged Learning.... 6. I understand that, as part of this immersion course, I will participate in the formation of the Course Covenant and will commit to this covenant once it has been formed. I understand that my violation of this covenant may result in my return from the immersion at my own expense.... Please indicate with X YES YES * Special note for PSR M.Div. students: Immersive Learning at PSR seeks to make it possible for all interested students to engage with immersion courses that stretch their awareness and strengthen their theological and multicultural capacities as leaders and change agents. In order for this course to meet the Cross-Cultural Contextual Immersion Course requirement for the Master of Divinity program, a conversation (in person, phone or email) with the Director of Contextual Learning at PSR is required. Once confirmation has been received, the Registrar will be notified that the course meets the student s MDiv requirement. Alternatively, this course can be selected as an elective. Signature Date Please print your name PSR Community Engaged Learning Immersion Application Form (REV 10/17) Page 5 of 5