"*" indicates required fields Personal informationName* First Last Father's NameRequired if you are under 18 at the time of the trip Mother's NameRequired if you are under 18 at the time of the trip Email Address* Email Address - ParentRequired if you are under 18 at the time of the trip Address* Street Address City State / Province / Region ZIP / Postal Code Cell Phone Number*Phone Number of Parent (emergency use only)*Date of Birth* Month Day Year City, State, Country of Birth*This is needed because, when we register our conference with hotels in Rome, Italian law requires that the hotels collect some basic information about conference participants. Specifically, they need each person's name, date of birth, place of birth, and nationality. Passport InformationPassport Name*If you already have a passport, enter your name as printed in the passport. If you do not have a passport yet, enter your full name exactly as you will submit it in the passport application. Visit travel.state.gov for instructions on getting a passport. Passport Number Passport Issuing Country*United States of AmericaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwePassport Expiration DateMake sure that your passport will have six months of validity beyond the date of your return trip. Italy will not permit a traveler to enter the country unless their passport is set to expire at least six months after the final day of travel. Month Day Year EducationSchool* Current Year in School* Major (if known) Participation in the UNIV ConferenceParticipation*Let us know if you are applying simply to attend the UNIV Conference or if you plan to formally participate in the conference. Be sure make your submission by the deadline. I will just attend the conference I will participate in the conference Participation Type*How do you plan to participate in the conference? I will submit and present a research paper I will submit a video I will submit a work of art I will compete in the Social Initiatives video competition I will compete in the team debates I will compete in the business case competition MiscellaneousElectronic Signature for Photo ReleaseParents must sign for applicants under 18 years of age. I hereby authorize and consent to the use and reproduction by YSI staff or an authorized agent or assignee of any and all photographs taken of the above-named applicant for the purpose of promoting YSI programs, without any compensation to me. All film, together with any prints, shall constitute property of YSI, solely and completely. Diet, MedicalDo you have any special dietary needs or medical conditions that we should be aware of?Reference*Who recommended this program to you? Comments
