Participant Application for Short-term Faculty-led Programs

Transcription

1 Participant Application for Short-term Faculty-led Programs DATE PERSONAL INFORMATION Name as it appears on your passport: (last) (first) (middle) Gender: Male Female Date of Birth: / / Do you smoke? Yes No mm dd yyyy (This information is for housing placement only) Passport ID number: Expiration date: / / mm dd yyyy Local Mailing Address: Phone: ( ) Cell: ( ) Bearmail: I am a (check one): Missouri State University student M-Number: Student from another college or university Name of institution: Adult Learner Guest of Program Director IF YOU ARE A COLLEGE STUDENT, PLEASE COMPLETE THE FOLLOWING: Year in school: Freshman Sophomore Junior Senior Graduate Student Number of credit hours completed: Cumulative GPA: Major/Minor: YOUR PREVIOUS FOREIGN TRAVEL/STUDY EXPERIENCE (please describe below): REFERENCES Please submit the names and contact information of two academic or personal references: PERSON TO BE CONTACTED IN CASE OF EMERGENCY Name: Relationship: Address: Phone Number: ( ) PROGRAM INFORMATION Program Name: Country: Course Number: Number of Credit Hours: Are you taking this class for credit? Yes No (example: IDS 397) Term of Study: Program Director: Application Deadline: (example: Summer 2012) HOW DID YOU HEAR OF THIS PROGRAM? Program Director Fellow student Department Newsletter or Department Web page or Social Media Program Flyer or Poster Study Away Fair or Study Away 101 Meeting Study Away Web page or Social Media

2 Participant Application for Short-term Faculty-led Programs, page 2 Your Name: Program Name: DISCIPLINARY HISTORY Have you ever been found responsible for a disciplinary violation (academic or behavioral misconduct) at Missouri State University? Yes No Have you ever been convicted of a misdemeanor, felony or other crime? Yes No If you answered YES to either of the above questions, please explain: PLEASE COMPLETE THIS APPLICATION AND ATTACH ALL REQUIRED DOCUMENTS. Your space in the program cannot be reserved until all documents have been received. You must submit the following: This completed and signed Participant Application Signed Statement of Responsibility, Release, Waiver of Liability & Hold Harmless Agreement Photocopy of Passport Identification Page International Student Identity Card (ISIC) Application Please submit a headshot of approximately 1.5 top to bottom, or a digital photo to [email protected] Program Director approval and signature (below) NON-REFUNDABLE DEPOSIT & BALANCE OF PROGRAM FEES A non-refundable deposit equal to 15% of the program fee is due with this application. By signing below, MSU students agree to be billed now for 15% of the program cost through their University accounts; other program participants must enclose their check or money order with this application. The balance of program fees is due by the deadline specified in the program flyer. MSU students will be billed through their University accounts; non-student participants must pay by check or money order by the deadline. Nonpayment of fees does not guarantee automatic withdrawal from the program. All program fees must be paid in full before the program departs. If a student is planning on financial aid to cover some or all program costs, the student must provide documentation to the Study Away Accounting Specialist. See the program flyer on the Study Away website for Payment, Cancellation & Refund Policies. Tuition fees are not included in the program fee and will be charged to your University account separately. Amount of Non-refundable Deposit: $ Balance of Program Fees: $ PARTICIPANT SIGNATURE By submitting this Application, I acknowledge that I am making a commitment to participate in this Study Away program. I certify that I have read the informational flyer for this program and understand the Program and Tuition Costs, Course Objectives and Credit Requirements, Deadlines, and Payment, Cancellation and Refund Policies. If I am forced to withdraw from the program for any reason, I will submit a written letter of withdrawal to the Program Director and Study Away Office. My date of withdrawal will be based on the date I submit the letter to the Study Away Office. By my signature below, I certify that the answers given on this application are complete and accurate to the best of my knowledge. I understand that submission of false information may result in my denial or expulsion from the program. Signature of Applicant: Signature of Parent (if applicant is under 18): Date: Date: PROGRAM DIRECTOR APPROVAL Signature of Program Director certifying Applicant s eligibility to participate in this program: Date: Please submit your completed Application, along with all required documents listed above, to the Program Director or to: Study Away Programs Missouri State University 301 S. Jefferson Ave., Suite 403 Springfield, MO USA Phone: (417) FAX: (417) [email protected] Web: Missouri State University is an Equal Opportunity/Affirmative Action Institution. Complete Non-Discrimination Policy Statement available at

3 STATEMENT OF RESPONSIBILITY, RELEASE, WAIVER OF LIABILITY & HOLD HARMLESS AGREEMENT In consideration for receiving permission to participate in a Missouri State University study abroad program, I hereby release, waive, discharge and covenant not to sue the Board of Governors of Missouri State University, its officers, agents, faculty, employees, agents, and volunteers (hereinafter referred to as University ) from any and all liability, claims, demands, actions, and causes of actions whatsoever arising out of or related to any loss, damage or injury, including death, that may be sustained by me, or to any property belonging to me, whether caused by the negligence or fault of the University, or otherwise, while participating in such course of activity, or while in the country or upon the premises where such activity is being conducted, while traveling to or from the country or premises where such program will be taking place, or while engaging in any activities related to the study abroad program. I am fully aware of and accept the risks of overseas flights, lengthy bus trips and travel by van, including delays and added expense, and the risks of living in a foreign country where laws and the judicial system are different from what I am accustomed to and where penalties may be harsh and constitutional safeguards may not exist. I am fully aware of the risks of acts of crime or terrorism, knowing that these conditions may be hazardous to my personal property and me. I am also aware of all the risks of living and traveling alone in a foreign country, should I purposely or accidentally separate myself from my project group or decide to remain abroad upon the end of this program. I am fully aware of and accept the risks of unfamiliar diseases existing in foreign countries and the lack of medical attention available under the circumstances, and I am further aware of and accept the risks of available living accommodations, knowing that the same may be hazardous to me and my property, and I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by me as a result of being engaged in such activity, whether caused by the negligence or fault of the University or otherwise. And, I am fully aware of the risks to which I will subject myself and my property, should I decide to remain abroad beyond the time that the program has come to an end, especially the risks of remaining in another country alone, without faculty advisors or University sponsorship. I agree to indemnify and hold harmless the University and covenant not to sue the University for any loss, liability, damage or costs, including attorney s fees, that the University may incur due to my participation in this program, whether caused by the University s negligence or fault or otherwise. It is my express intent that this release, waiver, and hold harmless agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased. I further agree that this document shall be construed in accordance with the laws of the State of Missouri in the United States of America. I certify that I have health care coverage (and will continue to have such coverage throughout the length of this program) which covers illnesses or injury suffered while on an off-campus program or trip. I agree that I am solely responsible for all costs for medical care not covered by my health insurance. I certify that I have no physical or medical condition that will impact my participation in the study abroad program or that I have disclosed any physical or medical condition which may require special medical attention or accommodation in writing to the director of the study away program.

4 I understand and acknowledge that the University may change the program including the itinerary, travel arrangements or accommodations at any time for any reason and that the University will not be responsible for any resulting losses or expenses. I understand and acknowledge that the University has the right to expel any student from the program in its sole discretion. Should I be expelled from the program, I understand that I will not be reimbursed any program costs and will be solely responsible for the cost of returning home. I understand and acknowledge that the University, in its sole discretion, has the right to cancel this program at any time and to require all participants to return to the United States. Additionally, I hereby grant Missouri State University permission to copy, print and distribute my study away statement and/or photos and to incorporate the work, in whole or in part, into the Study Away Annual Report, web site, and/or other promotional materials. I grant Missouri State University the right to edit the work for spelling, grammatical, sentence structure, and other errors. In signing this agreement and release, I acknowledge and represent that I have read the entire agreement, understand it, and sign it voluntarily as my own free act and deed, and no oral representation, statements or inducements, apart from the foregoing written agreement, have been made, that I am at least eighteen (18) years of age and fully competent, and that I execute this agreement and release for full, adequate and complete consideration fully intending to bound by the same. In witness whereof, I have hereunto set my hand and seal this day of, 20. Date Study Away Participant (Please Print) Study Away Participant Signature [EMERGENCY CONTACTS AND PRIVACY WAIVER ON FOLLOWING PAGE]

5 Emergency Contacts and Privacy Waiver The Study Away Office defines an emergency as a potential health risk and a medical, natural, social, or political disaster. I have listed my contacts below and give permission for the University to contact them in an emergency. I further authorize the University and its agents and employees to take such actions as they deem necessary in their sole discretion in the event of an emergency. Such actions shall include but not limited to administering first aid, providing medicine, and seeking medical care. Primary Contact: Name: Day Phone: Cell Phone: Address: Relationship: Evening Phone: Address: Secondary Contact: Name: Day Phone: Cell Phone: Address: Relationship: Evening Phone: Address: If your parents are not listed above, may we contact them in an emergency? Yes No Date: Study Away Participant Signature

6 SubmittoStudyAwayOffice MSUINTERNATIONALSTUDENTIDENTITYCARD(ISIC)APPLICATION IncludeaPHOTO Pleasesubmitaheadshotofapproximately1.5 toptobottom,or adigitalphototo YouwillreceiveyourcompletedISICcardatpre departureorientationorfromtheprogramdirector. PleasePRINT.MakesureyouhavesignedtheformbeforeturningitintotheStudyAwayOffice. PERSONALINFORMATION LastName FirstName DateofBirth(MM/DD/YYYY) / / LocalAddress:Street Local/MobilePhone City StateZip Address PermanentAddress:Street PermanentPhone City StateZip Programname: Country/State: EMERGENCYCONTACTINFORMATION Semester(s):SUFASP Year(s): LastName FirstName RelationshiptoApplicant PermanentAddress:Street Phone City StateZip Pleaseallow3 5workingdaysforprocessing. IherebycertifythatthisinformationistrueandIunderstandthatanyfalsestatementsonmypartmayresultinforfeitureofthe benefitsassociatedwiththiscard. Signatureofapplicant Date Forofficeuseonly:Cardnumber DateIssued Initials

7 ABOUTTHEINTERNATIONALSTUDENTIDENTITYCARD(ISIC) WhatistheInternationalStudentIdentityCard(ISIC)? ISICisanessentialdocumentforanystudenttravelingabroad.Inadditiontobeingtheonlyinternationallyaccepted studentidcard,theisicoffersmanybenefitstou.s.cardholders,including: InternationalRecognition YourregularstudentIDwon tbereadilyhonoredorevenunderstoodifyou retravelingoutsidetheunited States.TheISICprovidesinternationallyrecognizedproofofcurrentstudentstatus. StudentDiscounts YourISICgetsyoustudentdiscountstomorethan33,000locationsin103countries.Saveontravel, accommodations,attractions,retailshopping,mobilephoneandcallingcardcommunicationspackage,and manyotherservicesintheu.s.andabroad.beforepayingforanything,alwaysshowyourisicandaskfor studentdiscount.forcurrentdiscounts,visithttp:// LowStudentAirfares&FlightAssistance WiththeISIC,youareeligibleforreducedstudentairfares,offeredexclusivelythroughSTATravel,whichworks withanetworkoftravelagents.thesefares,onmanyscheduledairlines,cansaveyouhundredofdollarson internationalflights.checkfaresandbookflightsat: Ifyouneedassistancewithyourflightswhiletravelling,STATravel shelpdeskisavailable24/7: help.htm BasicIllness&AccidentInsurance TheISICprovidesno deductiblemedicalcoverageandemergencyassistancetou.s.cardholderswhentheyare travelingoutsidethe50unitedstatesanddistrictofcolumbia.theinsurancecoverage,whichisadministered bycsaandunderwrittenbystonebridgecasualtyinsurancecompany,includesuptothefollowinginbenefits: $25,000MedicalorDentalExpense(Noout of pocketlimitof$1,000) $300,000EmergencyAssistance(EmergencyMedicalTransportation) $5,000AccidentalDeath&Dismemberment AirFlightAccident $1,000AccidentalDeath&Dismemberment AllOther $100TravelDelay $100BaggageDelay Ifyouhaveamedicalemergencywhiletravelingabroad,callCSA semergencyprovidercollectat Forcompleteinsuranceinformationandclaimsprocedures,downloadtheDescriptionof Coverageathttps:// 24 HourEmergencyHotline Shouldanonmedicalemergencyarisewhileyouareabroad,calltheStudyAwayDirectorat FormoreinformationabouttheISICCardanditsbenefits, visithttp://