2015 UCI Summer Session: Application and Enrollment Form for Visiting International Students

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1 2015 UCI Summer Session: Application and Enrollment Form for Visiting International Students 1. PERSONAL INFORMATION TYPE or PRINT CLEARLY your name EXACTLY as it appears on your passport. Application instructions can be found online at summer.uci.edu. Last Name (Family Name) 1A. TRANSFER STUDENT INFORMATION Complete this section if you are currently an International Student at another U.S. school and are transferring to. Name of your current school First Name (Given Name) Your SEVIS ID number Middle Name o Male o Female Date of Birth (Month / Day / Year) / / Country of Birth Country of Citizenship Have you graduated from high school or secondary school? (Applicants must be 18 years of age or older to stay in Summer Housing) o YES o NO Have you previously attended our programs? o YES o NO If yes, provide UCI Student ID (optional) Are you currently attending a college or university? o YES o NO If yes, what is the name of the school? Do you need an I-20? o YES If yes, please select one: o for an F-1 visa o for school transfer o for change of status If you are transferring from another school in the U.S., please complete section 5 of the application. o NO, I do not need an I-20. I am (check one) o U.S. citizen / Permanent Resident o OTHER non-immigrant status (specify): Permanent Address in Home Country Street Address City Country Postal Code Permanent Telephone (required) Mailing Address for I-20 (if different from permanent address above) Street Address City Country Postal Code Telephone (required) Fax Number School Address City, State Zip Code Name of your advisor Advisor s Telephone Number at your current school Advisor s Advisor s Fax Number If you are a transfer student, will you be leaving the U.S. before starting our program? o YES o NO If yes, what is the date you will be leaving the U.S.? (MM/DD/YYYY) If transferring from another school in the U.S., please provide: o copies of all the I-20s from the schools you have attended o copy of your visa o copy of your passport photo page o copy of your CBP stamp in your passport or your I-94 admission record at 1B. AGENT/INSTITUTIONAL PARTNER INFORMATION If you have an agent or sponsor, please complete this section. Otherwise, skip this section. Agency/IP Name Agency/IP Address City, Country Postal Code Name of your representative Representative s Telephone Number Representative s Representative s Fax Number Important: Our office often receives requests from your agent/representative to release your financial and academic records to them. Under University policy, your written consent is required to release your information to a third party. To give permission to release your financial and academic information to your agent/representative, you must complete and submit the Consent to Release Educational Record form along with your application. Page 1 of 4

2 2015 UCI Summer Session: Application and Enrollment Form for Visiting International Students 2. SELECTION OF PROGRAMS AND COURSES A. Check summer.uci.edu/courses for updated course information and offerings. Please select up to 2 UCI courses. Students must enroll in a minimum of 6 units per session to support an F-1 visa. In addition, include 2 alternate course choices in the event the course you selected is full. You will receive a letter grade for each course you select. If you choose the option of pass/no pass, let us know and we will update your registration request. Course Selection: Select the program you plan to attend o Session I (June 22 - July 29) o 10-week Session (June 22 - August 28) o Session II (August 3 - September 9) o Session I and II (June 22 - September 9) Important: Students enrolling in a Summer Session course are expected to have completed any noted prerequisite requirements prior to the beginning of class. It is strongly encouraged that students do not register in courses that require a prerequisite. Please note that Summer Session writing courses are not open to International Students. Courses Session Department & Course Number 5-Digit Course Code Units Course Fees ($339 per unit) SAMPLE Asian American Art History Art History $1356 Alternate 1 Alternate 2 ACADEMIC ENGLISH Students have the option of enrolling in Academic English courses to assist with English speaking, reading, and comprehension to complement enrollment in another academic course. Maximum numberof units enrolled per session is 10-units. Students may exclusively enroll in Academic English courses, if they do not meet the minimum English Proficiency Requirements. Review our website for more details. Choose one Courses Department & Course Number Units Course Fees o Session I o Session II ESL Reading and Vocabulary AC ENG 22B 2.0 $678 o Session I o Session II University Writing and Communication AC ENG $678 o Session I o Session II Business English AC ENG $678 o Session I o Session II Film Media and American English and Culture AC ENG $678 o Session I o Session II Advanced Conversation AC ENG $678 B. English Proficiency Requirements Proof of English proficiency is required for enrollment in Summer Session. A TOEFL score of 213 on the CBT, 79 on the ibt, 550 on the paper-based TOEFL, 685 on the TOEIC, or 6.5 on the IELTS is necessary to attend Summer Session. Type of Test: o TOEFL o TOEIC o IELTS o OTHER Score: Please enclose copy of score report. C. Verify Program and/or Course Selection This section to be completed by student. I have read and understand the policies listed in the Student Services section of the UCI Summer Session website regarding academic information, registration, fees and refunds. I understand that all fees are pending final approval by the Regents of the University of California, all fees are subject to change at any time, and I will be responsible for all resulting increases in fees. Signature Date Page 2 of 4

3 2015 UCI Summer Session: Application and Enrollment Form for Visiting International Students 3. FINANCIAL INFORMATION All students applying to Summer Session need to complete this section. Remember to include a statement from your bank certifying that you have sufficient funds to cover tuition and living expenses for the duration of your stay. All funds must be specified in U.S. dollars. Funds Required Per Program Summer Session I $6,000 Summer Session II $6, Week Session $11,000 Session I and II $11,000 Do you intend to bring your spouse or child(ren) with you? o YES (Contact us for further instruction) o NO Provide one of the following proofs of funds: Original copy of your bank statement OR Letter on bank letterhead certifying that the required funds for your program/s is available. The letter must include your name or the account holder s name if different from self; the required dollar amount for the program/s; the name, title and signature of the bank official and the bank s seal OR Complete Certification by Bank Representative section below If someone else is supporting you, he or she must sign and consent to the statement of financial support below. Certification by Bank Representative (Required only if you are unable to obtain a bank statement) Account Holder s Name Name of Bank representative Bank Telephone Bank Address City, Country, Postal Code Representative s Signature Date (within 90 days) Official Bank Seal or Stamp Statement of Financial Support The person who is financially responsible for you must read and sign the statement below. If you are financially responsible for yourself, you may sign the statement. I have read the information regarding the cost of tuition and living expenses for the period of study at UC Irvine. I certify that these funds are available, and I accept full resonsibilities for these expenses. Name of Person Signature Relationship to Student Date 4. PAYMENT INFORMATION Application/International Student Fee (non-refundable) $750 Campus Fee (non-refundable) $250 Summer Session Course Fees* ($339 for visitors/unit -- additional materials and/or lab fees may apply) $339 for visitors/unit x (number of total course units) = Materials or Lab Fees (non-refundable) $ Health Insurance** (Session I = $260 Session II = $260 Session I and II = $ week Session = $430) Housing Placement Fee (non-refundable) $250 Airport Pick Up (non-refundable) Los Angeles (LAX) $80 or Orange County (SNA) $45 $ GRAND TOTAL in US$ = $ All fees are subject to change without notice. For updated information visit the web site: summer.uci.edu/international/enrollment/fee_descriptions.aspx * Fee is based on an estimated $339 per unit fee (most courses are 4-unit) plus a $250 campus fee. Additional materials and/or lab fees may apply depending on your chosen course. The $339 per unit fee is based on the current tuition. The Summer Session tuition is subject to change by action of the UC Regents at any time for all UC campuses, including UC Irvine. ** Enrollment will not proceed until payment has been received by Summer Session. Note that it can take up to 5-7 business days after you submit the application. ** A charge for mandatory health insurance will appear on your fee statement unless you submit an Insurance Waiver form no later than program start date. Students accompanied by dependents may purchase additional coverage. $ $ Payment Method o Bank-to-bank tranfer via Western Union Business Solutions o Money order or bank check payable to UC Regents (checks must be issued from a U.S. banking branch) o Credit card**: o VISA o MasterCard o American Express Cardholder s Name Card Expiration Date Billing Address Billing Zip / Postal Code Authorizing Signature Page 3 of 4

4 2015 UCI Summer Session: Application and Enrollment Form for Visiting International Students 5. EMERGENCY CONTACT In case of an emergency, whom may we contact? Name Telephone Street Address Country Relationship (required) City Postal Code 6. APPLICATION CHECKLIST o Completed Application o Signatures in sections 2, 3, 4, and 7 o Copy of your passport (page with your name and photograph) o Copy of English proficiency score report o Proof of Funds: Bank Statement OR Letter on Bank letterhead OR Certification by Bank Representative with Official Bank Stamp/Seal o Payment: Check OR Money Order OR Credit Card information o Insurance Waiver Form (if not taking UCI Insurance) o Consent to Release Educational Records Form (if applicable) Additional Items if you are a Transfer Student o Copy of your F-1 Visa o Copies of all I-20s from the schools you have attended o Copy of your CBP stamp in your passport or your I-94 admission record at 7. STUDENT SIGNATURE Mail or fax your application with all supporting documents to us. Via Regular Mail PO Box 6050, Irvine, CA OR Via Express Mail Pereira Drive West of E. Peltason, Building 231 Irvine, CA OR Via Fax +1 (949) Contact us directly with any questions or concerns. Tel: +1 (949) , Monday - Friday, 8:00am - 5:00pm PST internationalsummer@uci.edu I certify that the information on this entire form is correct to the best of my knowledge. Student Signature Date Page 4 of 4

5 2015 UCI Summer Session: Housing Form Part I for Visiting International Students A NOTE ABOUT HOUSING... Housing is available on a first-come, first-served basis during your UCI Summer Session program. If you apply for housing, we will contact you with further information. Applicants must be 18 years of age or older to stay in Summer Session housing. 1. HOUSING PREFERENCE This form is to be used as a preliminary housing application. Once accepted, Summer Session will send you Housing Form Part II. Housing space is limited and is offered on a first-come, first-served basis. o Summer Dormitory (See the program website for additional information) o I will arrange my own housing (Skip this page if you are making your own housing arrangements) 2. PERSONAL INFORMATION TYPE or PRINT CLEARLY your name EXACTLY as it appears on your passport. Last Name (family name) Middle Name o Male o Female Date of Birth (Month / Day / Year) / / Country of Birth Country of Citizenship Native Language First Name (Given Name) 3. CONTACT INFORMATION Please TYPE or PRINT CLEARLY. This will be our primary form of contact. Student Agent or IP (if applicable) Telephone Number Fax Number 4. CHECK-IN / CHECK-OUT DATES AND FEES For additional information about housing and fees, refer to our website at summer.uci.edu. Students in UC Irvine summer dormitories will sign a contract committing to the duration of the entire program. Check-in Date Check-out Date Number of Nights Total Fee* Session I June 20 July $904 Payment will be requested with your housing contract, which will be sent to you after receiving this preliminary housing form is received by our office. Session II Session I & II August 1 June 20 September 10 September $904 $1855 * The amounts in the chart are estimated costs and are subject to change. There is an additional $250 non- refundable housing placement fee. DORMITORY INFORMATION Dormitory housing provides easy access to classrooms and libraries. The dormitory is located 15 minutes walking distance from classes. The building is co-ed housing with gender-specific bedrooms. You will be provided with basic dormitory essentials including linens, towels, and kitchenware. Each student will have one bed, desk and dresser. Meals are not included. Meal plans may be purchased upon arrival. 5. STUDENT SIGNATURE I certify that the information on this entire form is correct to the best of my knowledge. Student Signature Date Mail, fax, or your application to us: Via Regular Mail PO Box 6050, Irvine, CA Via Express Mail Pereira Drive West of E. Peltason, Building 231 Irvine, CA Contact us with your questions: Mr. Michael F. Lyons Director of International Partnerships Tel: +1 (949) Fax: +1 (949) Visiting International Tel: +1 (949) Fax: +1 (949) internationalsummer@uci.edu

6 2015 UCI Summer Session Statement of Financial Support The person who is financially responsible for the student/applicant must read and sign the statement below. I have read the information regarding the cost of tuition and living expenses for the period of study at University of California, Irvine, Summer Session. I certify that these funds are available and I accept full responsibility for these expenses. PRINT NAME (FIRST AND FAMILY NAME) OF PERSON FINANCIALLY RESPONSIBLE DATE PRINT (FIRST AND FAMILY NAME) NAME OF STUDENT DATE RELATIONSHIP TO STUDENT SIGNATURE OF PERSON FINANCIALLY RESPONSIBLE DATE This statement of financial support can also be found directly on the application and enrollent form. If using this form, the original form may be mailed to: VIA EXPRESS MAIL University of California, Irvine Pereira Drive West of East Peltason Building A, #231 Irvine, CA VIA REGULAR MAIL University of California, Irvine PO BOX 6050 Irvine, CA PO Box 6050 Irvine, CA Telephone (949) internationalsummer.uci.edu

7 2015 UCI Summer Session Health Insurance Waiver & Guarantee of Independent Coverage Students who wish to waive UCI health insurance must submit this Waiver with their application. All students who do not complete this Waiver by the program start date will automatically be enrolled in the UCI health insurance plan, and will be responsible for paying those fees. Please write clearly. Family Name Telephone Permanent Street Address Country First Name (required) City Postal Code Select the program the applicant will attend o Session I (June 22 - July 29) o 10-week Session (June 22 - August 28) o Session II (August 3 - September 9) o Session I and II (June 22 - September 9) This waiver is to certify that I, the above named student, am waiving coverage of the health insurance plan offered to me by the University of California, Irvine, University Extension Program in Summer Session (UCI UNEX), for coverage during the above-specified program dates. In addition, because I am waiving the UCI UNEX health insurance, I am guaranteeing that I will instead be covered by an independent health insurance plan which I will arrange myself. This independent health insurance plan meets the following minimum required coverages. $500,000 Maximum benefit per Policy Year $25,000 Minimum coverage for Evacuation Expenses to your home country if necessary $10,000 Minimum coverage for Repatriation of Remains to your home country in case of death The deductible does not exceed $75.00 per injury/illness I understand that during my program of study, adequate health insurance coverage, as defined by the minimum coverages above, is required by UCI UNEX. Insurance Company Name Policy Number Contact Phone Number Coverage Dates SIGNATURE DATE 2015 Deadlines to submit waivers: Session I: May 29 Session I and II: May week: May 29 Session II: July 2 PO Box 6050 Irvine, CA Telephone (949) internationalsummer.uci.edu

8 2015 UCI Summer Session Consent to Release Educational Records I,, consent and authorize any official in the University of California, Irvine, Summer Session to release my 2015 educational records, including my student identification number, course enrollment, and grading options, fees and payments, final course grades, housing related information, and conduct meetings in in which I m enrolled or to an authorized representative of said organization. The UCI Summer Session Partner representatives will use the released information to track the academic performance and/or program participation of the forenamed student for financial sponsorship or other considerations. This disclosure also allows for the UCI Summer Session Partner representatives to make enrollment changes on the forenamed student s behalf. Such changes include course changes and grade option changes. The recipients of this disclosure understand that the disclosed information must not be re-disclosed without the prior consent of the student. The University of California, Irvine, Summer Session will provide the student with a copy of the disclosed records upon the direct request of the forenamed student. I understand that my signing of this consent form is voluntary. This release complies with the Federal Family Educational Rights and Privacy Act (1974). SIGNATURE OF STUDENT AND DATE SIGNATURE OF REPRESENTATIVE AND DATE PRINTED NAME OF STUDENT PRINTED NAME OF REPRESENTATIVE PRINTED NAME OF PARTNER ORGANIZATION ADDRESS OF REPRESENTATIVE PO Box 6050 Irvine, CA Telephone (949) internationalsummer.uci.edu