SVCC International Travel Data Sheet
Please fill out this sheet and submit it along with the other documents. Participants must be a United States citizen to participate in this program.
Print name as it appears on the passport
Address_________________________________________________________________
City_____________________________ State ______________Zip Code_____________
Home phone__________________________ Work phone________________________
Cell number_____________________ Email address ____________________________
Have you made a $50 contribution to the SVCC International Scholarship Fund? Y or N
If no, submit a check for $50 or more to the SVCC International Scholarship Fund.
Are you traveling along? Yes or No If no, would like a roommate? Yes or No
Do you want a roommate of the same gender? Yes or No
If yes, who will be your roommate? ________________________________________
Do you require a special diet? Yes or No. Explain _______________________________
Do you have a valid passport that is good for six months from the date of travel? Y or N
I have read and agreed to the terms and conditions as stated in the SVCC International Education Travel Agreement, the SVCC Assumption of Risk Statement, the SVCC International Travel Policy and the Drug and Alcohol Abuse Policy.
Please sign all the necessary documents and submit them along with your initial deposit to: Dr. Percy Richardson, Southside Community College, 200 Daniel Road, Keysville, VA 23947.
Documentation Checklist
____ Initial Deposit
____ Single Supplement Check
_____ Check for late fee and tip
_____ International Education Travel Agreement
_____ Drug and Alcohol Abuse Policy
_____ Assumption of Risk Statement
_____ Copy of your passport
_____ Contribution to the SVCC International Scholarship Fund
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