2023 CIVIL RIGHTS' SOUTH Study USA Program - Student Application Form

This is your Study USA Application Form. It must be completed before your appointment with Luli Szeinblum to secure your spot.

Completing this application DOES NOT make you eligible, or accepted, into the program, but it is a pre-requirement to secure your spot.

Name Name First Last
Panther ID
FIU Email Address
Best Phone Number to Be Reached At Best Phone Number to Be Reached At - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Gender
Major/s
FIU GPA
Academic Standing

Academic Standing Good Academic Probation Conduct Probation On Appeal
Status

Status Freshman (0-30 credits) Sophomore (31-60 credits) Junior (61-90 credits) Senior (91-120 credits)
Emergency Contact's Name Emergency Contact's Name First Last
Emergency Contact's Relation
Emergency Contact's Phone Emergency Contact's Phone - ### - ### ####
Emergency Contact's Email Address