Chicago Center for Urban Life & Culture

1. First Name
2. Last Name
3. Email
4. Phone Number
5. Current Street Address
6. Current City
7. State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of Columbia
8. Zip Code
9. Permanent Street Address
10. Permanent City
11. State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of Columbia
12. Zip Code
13. Date of Birth

14. Gender

    Male
    Female
15. Race/Ethnicity (Optional) Not Applicable African-American American Indian/Alaska Native Asian ... Native Hawaiian/Other Pacific Islander Asian Caucasian Hispanic

Chicago Center Program of Study You Are Applying For:

1. January Term 20
2. I will be completing my BSW
3. May Term 20
4. I will be in a student teaching program
5. Summer Session 20
6. Fall Semester 20
7. Spring Semester 20
8. College or University currently attending
9. G.P.A
10. Graduation Date

11. Year you will be when you attend Chicago Center

    First Year
    Senior
    Soph.
    Grad
    Junior
12. Majors
13. Minors

1. Have you ever been expelled from a college or university, or been subject to disciplinary action for any

   Yes
   No
2. If yes, please explain

1. Emergency Contact First Name
2. Emergency Contact Last Name
3. Relationship
4. Phone Number
5. Street Address
6. City
7. State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of Columbia
8. Zip Code

1. I am auditing this program and do not wish to receive credit
2. I will receive credit from Millikin University as a "Guest Student"

For students wishing to use a language in addition to English, please fill out the form below.

1. Language Other than English

2. Comprehension:	Below Average	Average	Above Average	Excellent
   Of carefully spoken language
   Of written language
   Of colloquial speech by native speakers

3. Oral Expression:	Below Average	Average	Above Average	Excellent
   Fluency
   Range of expressive strategies
   Pronunciation
   Grammar Correctness
   Phone Skills

4. Writing:	Below Average	Average	Above Average	Excellent
   Simple messages, related to everyday life
   Correct grammar usage

5. If you have used this language in settings other than your campus, please indicate where, in what capacity and for how long:

1. How did you learn about Chicago Center?
2. What influenced you most to apply?

1. Upload Resume
2. Upload Essay

   What are your personal and academic reasons for choosing to attend Chicago Center?

1. Select the program you are applying for to continue to the next page Select Urban Academic Practicum TeachChicago! Urban Social Work Practicum January Term May Term Summer Session