Gap Experience registration form 2011

Please note all fields marked with * must be completed in order to submit this form.

Destination and Timing

Country:*
Name of Gap Experience provider:* eg. Antipodeans Abroad
During:*
Dates of travel:*

Your Personal Details

Title:*
Family name:*
Given name(s):*
Home phone:*
Work phone:*
Mobile:*
Email address:*
Date of birth:*
Sex:	Male Female
Emergency Contact Person Emergency contacts are used by UniSA in the event that you are involved in a major incident overseas, or if we urgently require information about your whereabouts or your program and we are unable to contact you.
Name:*
Relationship:*
Address:*
Suburb/city:*
Postcode:*
Home Phone:*
Work Phone:*
Mobile:*
Email:*

Your Current Details

Program in which you are deferred:* eg. Bachelor of Arts (International Studies)
University:*
Are you an international student?:*	Yes No
Do you want to receive credit?:*	Yes No

Note: To receive credit of 4.5 units (1 course) you must subsequently enter programs in the Divisions of Business or Education, Arts & Social Sciences. You must also attend the UniSA pre-departure workshop and complete the required assessment with a pass grading.

How did you find out about the Gap Experience program?

Student Declaration

I agree to inform the UniSA International office immediately if there is any change to the information given in this application.
I understand that the University of South Australia may vary or cancel any decision it makes if the information I have given is incorrect or incomplete.
I declare that the information provided by me in this application is true and complete.*

Yes No

Date:*

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