Study Abroad and Global Learning Acceptance Packet

Transcription

1 Course Approval Study Abroad and Global Learning Acceptance Packet Western Kentucky University Office of Study Abroad and Global Learning Grise Hall 128, 1906 College Heights Blvd. # 11064, Bowling Green, KY Phone: (270) Fax: (270) AP Name: WKU 800#: I understand it is my responsibility to ensure that all study abroad courses are approved for transfer credit to WKU, and that if the course(s) taken during a study abroad program deviate from those listed on the Course Approval section, I will need to file an Amended Study Abroad Course Approval Form during or immediately following my study abroad program, and that failure to do so will delay in the posting of the credit to my academic transcript and may delay my ability to register or graduate in a timely manner. 1 If you are registering for WKU course(s), indicate Course Number and Title at WKU. No Department Head signature required. Appropriate Academic Advisor signature required. 2 If you are registering for a NON-WKU course, indicate Previously accepted at WKU box if courses have been previously accepted by WKU. You can see which courses have been accepted at this website: If the courses you intend to take have NOT been accepted previously, please write in the course and take to the department head most closely affiliated with the intended study abroad course for his/her approval and signature. If you are in a NON-CREDIT program, write NON-CREDIT in the Course Number/Title line. No Academic Advisor signature required, but the non-credit Program Leader must sign as Advisor. Al languages course MUST be approved by the Advisor or Department Head of Modern language Department (FAC 215) Course Number & Title at Host University 1 WKU Equivalency Course # HRS Previously accepted at WKU 2 Yes/No Signatures of Appropriate Department Head or Designee (If previous answer is NO) Date Signed by Dept Head or Designee Your academic advisor should approve your study abroad course(s) as they pertain to your degree program or icap Audit. Academic Advisor (print): Date: Phone: Signature:

2 Student Responsibilities Statement I understand that it is my responsibility to ensure that the academic transcripts be sent in a timely manner to WKU at the following address: WKU Study Abroad & Global Learning, 1906 College Heights Blvd. #11064, Bowling Green, KY , and I understand that the transcript and the Study Abroad Acceptance Form will only be forwarded to the WKU Registrar s Office for recording when both forms are in agreement, and that once recorded, the credit will appear on my unofficial transcript as part of my permanent record, and, I understand that the WKU Registrar will record all courses/grades that appear on my transcript; and, I understand that, during the fall/spring terms, if I drop below full-time status while at another institution, WKU may allow me to petition so that my financial aid will remain in place for the term in which I am studying at another institution and for the subsequent term; and, I understand that courses taken abroad may not duplicate credit already earned at WKU, and that all credits earned overseas will contribute to my cumulative GPA and/or hours earned, and that WKU will award credit based on the Academic Requirements and Regulations published in the undergraduate and graduate catalogs; and, I have read all program material provided to me and have had the opportunity to make inquiry about the program, including, but not limited to, type of facilities, healthcare, housing, food, transportation and personal safety conditions expected in the locale, the type of activities and physical requirements necessary for the successful participation, and consulted the Centers for Disease Control and the U.S. Department of state web sites; and, I understand that I am free to undertake independent travel, defined as travel before or after the official start and end dates of the official program, and as travel independent of sponsoring institution officially-sanctioned travel, and acknowledge the risks and personal liability of undertaking such travel, and accept responsibility for my personal safety, health, legal aspects, and costs associated with outside-program travel; and, I am aware the option to obtain personal liability coverage and may do so at my own expense; and, I understand my personal responsibility to understand the risks of foreign travel and participation in study abroad programs and that WKU does not guarantee quality of the participation experience, including any non-wku sponsored programs, and I recognize and acknowledge the risks of any experience outside my own culture and to adjust my behavior, dress, and activities to maximize my own and the group s safety; and, I am responsible for controlling, comporting and conforming my behavior while participating in my particular Program, which as a guest in another country, certain behaviors, which are considered unacceptable and could lead to possible disruption of the program, that I shall conduct myself in an appropriate manner, which does not infringe upon the customs and mores of the country in which the program is being conducted, nor upon the rights and safety of the student and of other participants of the program; and, I understand that behavioral standards shall be applicable during the course of the program both when in the company of other program participants and when I am physically separated from other program participants, and that any behavior that is in violation of WKU policies could result in my being dismissed or suspended from the program without a refund, and returned to the United States at my own expense at the earliest possible time as determined by the program leader; and, I understand that WKU does not employ or retain mental health professionals abroad, and that I should consult with my current mental health provider prior to engaging in a study abroad program to discuss the potential stress of studying abroad, and that I know that mental health treatment may not be as widely accessible abroad as it is in the United States; and, I understand that my Program may require medical information to be eligible to participate in the Program and that I will provide the information as required, and I understand that I am free to utilize transportation provided via WKU or choose a mode of transportation independent of that provided by the University at my own risk and expense, and I voluntarily and willingly participate and represent that I am medically fit to engage in the international activity and travel, and I further agree voluntarily to assume all risks including, but not limited to, accident, illness or damage to my person and property to the extent not covered by insurance, or liability of third parties, and I acknowledge that foreign travel may entail risks of personal and /or bodily injury including death and property loss, including those

3 resulting from kidnapping, criminal activity, war, terrorist attacks, lack of access to health care, food or beverage contamination, public health problems, and unsafe local transportation, and that I understand foreign facilities may not meet United States accessibility standards, and I acknowledge that WKU shall have authority to cancel or terminate the travel and related on-site activity in accordance with its policies of best judgment including cancellation of international travel for political developments and/or State Department travel warnings with no refund guaranteed, and I understand that I am personally liable for all my visa, public health and customs compliance, and that if I am not a U.S. citizen or permanent resident alien, reentry into the United States may not be automatic, and I authorize WKU to take whatever actions deemed warranted and appropriate regarding my health and safety. I, (print name), agree to abide by WKU policies, including the entirety of this WKU Study Abroad & Global Learning Acceptance Package, the WKU Student Handbook, and agree to indemnify and hold harmless Western Kentucky University, its employees, agents, and /or officers from any and all loss, damage, or expense incurred as a result of my participation in said programs. If above signatory is under 18 years of age, a parent/legal guardian shall sign below: I, (print name), acknowledge that I have carefully read, agree to and understand the above statements. Phone: Relationship to above signatory:

4 Consent of Release of Confidential Information I, (please print), being a student at Western Kentucky University ( WKU ), hereby give my written consent and permission to the Office of the Vice President for Student Affairs and to the Office of Judicial Affairs to release my student records, limited and pertaining to judicial records only, to the Office of Study Abroad & Global Learning. By execution of this document, I acknowledge my understanding that only information pertaining to any sanctions WKU might have against me will be shared and may be considered for my acceptance to a Study Abroad Program. I also understand that personal information not relevant to a judicial sanction will not be shared with the Office of Study Abroad & Global Learning. If above signatory is under 18 years of age, a parent/legal guardian shall sign below: I, (print name), acknowledge that I have carefully read, agree to and understand the above statements. Phone: Relationship to above signatory: SAGL Approval & Date Student is cleared to study abroad Student is cleared to study abroad with comment Student is not approved to study abroad Notes:

5 International Medical Insurance Academic Health Plans (AHP) study abroad medical insurance is mandatory for WKU students & employees traveling with either credit or non-credit programs outside the United States. AHP study abroad medical insurance will be in effect ONLY while you are outside the U.S. during your approved program dates. If you plan to travel before or after the approved dates, you will need to make arrangements for your own medical insurance. The current premium is found at the Study Abroad website. WKU s Study Abroad & Global Learning office (SAGL) will determine the method of payment and amount based upon the duration of the travel. SAGL will arrange payment with AHP, who will provide insurance cards and information for each policyholder. Please note that some providers and scholarships require proof of insurance or require purchase of specific medical insurance that is secondary coverage. The AHP policy will provide you proof of insurance. Make sure you are clear on your situation prior to completing this form and submitting your support material as listed below. CHECK ALL BOXES THAT APPLY: Check if you are participating in a WKU program: I understand that I will be billed for the Academic Health Plans study abroad medical insurance for my international travel. Check if your are participating in a non-wku program, but will require AHP Insurance: I understand that I will be billed for the Academic Health Plans study abroad medical insurance for my international travel fulfill the proof requirement. Check if your non-wku program requires specific medical/evacuation/repatriation insurance as part of the program costs: My program, (print provide name), requires SPECIFIC international medical/evacuation/repatriation insurance as part of the total program costs and I have attached (1) the program provider's statement to this effect and (2) the policy coverage. Example: KIIS and CCSA include in program costs. Include copy of insurance policy if available. Check if you are a scholarship/grant recipient AND are required to purchase specific medical/evacuation/repatriation insurance: My scholarship/grant, (print name of scholarship/grant), requires that I purchase specific international medical/evacuation/repatriation insurance in order to accept the award and I have attached (1) the sponsor's statement to this effect and (2) the policy coverage. The Worldtopper Scholarship and Honors Travel Grant are NOT included here. Include copy of insurance policy if available. Together, WKU Health Services and the SAGL Director will review the provided documentation and determine if the requirement to purchase the mandatory WKU international insurance may be waived for you. I, (print name), acknowledge that I have carefully read, agree to and understand the above statements. Signature: If above signatory is under 18 years of age, a parent/legal guardian shall sign below: I, (print name), acknowledge that I have carefully read, agree to and understand the above statements. Phone: Signature: Relationship to WKU student: Student Information Gender : M or F Birth Date: Departure Date: Return Date: Please provide exact travel dates.

6 Emergency Contact Information EMERGENCY CONTACT INFORMATION I provide the following U.S. Emergency Contact Information to WKU and authorize the WKU to contact them in the event of an emergency (NOTE: At least one of the contacts listed below should have a valid passport to travel outside the United States or these individual won t be able to travel outside the U.S.): Name 1: Relationship: Preferred Phone: Passport Number: Passport Origin: Mailing Address: Name 2: Relationship: Preferred Phone: Passport Number: Passport Origin: Mailing Address: Attach a copy of your passport, including the visa page when applicable. Print entire Study Abroad Acceptance Package, get appropriate signatures and return to: Study Abroad & Global Learning Office Grise Hall College Heights Blvd. # Bowling Green, KY Phone: (270) Fax: (270) study.abroad@wku.edu It is recommended that you keep a copy of this document for your records.