Name:     

 Freshman Sophomore Junior Senior

College:

E-mail Address:

Home Address:

Preferred Houston Mailing Address:

Anticipated length of stay: <select one> 3-4 weeks 4-5 weeks 5-6 weeks 6-7 weeks 7+ weeks

Are you applying for any Rice scholarships to fund your trip? Yes

If you are applying for Rice scholarships, please list them.

If you are applying for the Leadership Rice program, is your participation in the Summer Service Trip dependent on your acceptance into the program? Yes

If you have any additional comments, special concerns or questions, please add them here: