Crossroads III Application

If you have any questions or concerns, feel free to email us at emorycrossroads@gmail.com.

Personal Information
Name * First Last
Preferred Name (if different from above)
Emory ID (7-digit number) *

Please enter your 7-digit [numeric] Emory ID. This can be found on your OPUS account.
I am currently attending the: Atlanta Campus Oxford Campus
Home Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Best number to reach you * - (###) - ### ####
For International Students: If you have an American number, please enter that. If you do not yet have one, please enter 000-000-0000.
Date of Birth * / MM / DD YYYY
Preferred Email Address *
Gender * Man Woman Other
Ethnic Background *

Write other if you prefer not to specify.
Religion *

Write other if you prefer not to specify.
T-Shirt Size * X-Small Small Medium Large X-Large 2X-Large
Dietary Restrictions
Allergies
Ability Restrictions
Are you an International Student? Yes No
If you are an International Student, you can ONLY attend X2 since X1 would overlap with the International Student Orientation.
Emergency Information
Name of Emergency Contact * First Last
Relationship to Applicant *
Phone Number * - (###) - ### ####
Alternative Phone Number - (###) - ### ####
Name of Family Doctor First Last
Doctor's Office Phone Number - (###) - ### ####
Health Insurance Policy Number

International Students: Enter 00000 if you don't yet have this information. Please send us an update when you get your Health Insurance Policy Number
Additional Questions
How did you learn about this retreat? Emory Website Staff Student Social media (Facebook, Twitter, etc.) Advertisement E-mail Other
If referred by a student, by whom?
In a paragraph, explain why you would like to attend the Emory Crossroads retreat. *
How do you feel that attending the retreat will shape you as an individual and positively contribute to your Emory experience? *
Model Release Form

I hereby grant permission to the Emory Crossroads Retreat and Office of Multicultural Programs and Services photographers and film crew to take recorded statements, photographs, or film of myself during the academic year 2012-2013.

I understand that these recorded statements, photographs, and film may be used by the Office of Multicultural Programs for educational training without any liability on the part of the Emory University, its departments and/or employees. I understand that the interviewing and photographing/filming on these dates are being carried out with my permission and consent and I assume full responsibility for the release of information about myself. I understand the sequences may be used in Digital Video Disks, CD-ROMs, and pod casts for the purpose of teaching about student programming and non-commercial use.
Release * Yes No
Name of Person Interviewed, Photographed, or Filmed * First Last
Online Signature *
Date * / MM / DD YYYY
Online Signature of Parent/Guardian if Applicant is under 18 years old.
Date / MM / DD YYYY
Upload a Headshot *

Please upload an appropriate headshot to be used for the booklet.

Crossroads III Application

Crossroads III Application

Personal Information

Emergency Information

Additional Questions

Model Release Form