Gap Year Program Application

Have you ever attended Defiance College? *

Yes

No

If yes, dates attended:

First name: *

Middle name:

Last name: *

Date of birth: *

Street address: *

City: *

State: *

Zip code: *

Day telephone: *

Personal email: *

Do you have an international immigration visa? *

Yes

No

If yes, list classification (F1, J1, etc.):

I am applying for admission to Defiance College for: *

Fall 2020

Spring 2021

I want to take the following courses: *

COVID-19 Impact on Food Security (Fall 2020)

The Economic Impact: Protecting the Poor During COVID-19 (Fall 2020)

COVID-19 Impact on Education Equity and Inclusiveness (Spring 2021)

The Capacity of Communities to Manage the Global Health Risk of COVID-19 (Spring 2021)

I understand that I am responsible for paying tuition before the start date of the above selected courses. The current tuition rates are published each year in the Undergraduate or Graduate Academic Catalog. In the event that I leave Defiance College with an outstanding student account balance, College services may be withheld (e.g. grades, transcripts, diploma, class registration), fees may be added, and/or the outstanding balance may be placed with a third-party collection agency. Collection fees, which may be based on a percentage at a maximum of 33% of the debt and/or reasonable attorney fees, will be added to student balances placed for collection. In the event that my account is delinquent, my submission of this form signifies that I authorize Defiance College and anyone acting on its behalf to contact me regarding my unpaid balance.

Marking "I agree" serves as my electronic signature of agreement that the information provided in this form is true: *

I agree

Apply

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