Application Checklist

Transcription

1 International Professional Field Study and Language Immersion Programs Application Checklist Use the following checklist to make sure you have included all the necessary items for a complete application. All application materials should be returned to: Aaron M. Gorenc, Room G130 Fox Valley Technical College, Global Education and Services 1825 N. Bluemound Drive, P.O. Box 2277, Appleton, WI Tel: ; <gorenc@fvtc.edu> *Check individual program flyers to determine application and deposit deadline* Deadline for All Materials: 30 Days Prior to Departure The following items constitute a complete application: Complete and SIGN application form. Passport not required to apply; will be required to travel. Deposit of $200 due with application. Cash or Checks made payable to Fox Valley Technical College accepted. SIGN verifying you have read the Release, Waiver of Liability and Hold Harmless Agreement form. SIGN verifying you have read the Medical Agreement and Release form. SIGN the FVTC Cancellation Policy verifying you have read and understand the policy. Complete and submit participant profile form. Complete two (2) Faculty Recommendation Forms (current students only). Can be submitted at a later date. Complete Faculty/Participant Agreement Form (if needed). Signatures of instructors from each course that will be missed due to participation in the program. Can be submitted at a later date. Register for International Professional Field Study Course or Language Immersion Program through MyFVTC. Pay remaining balance directly to your FVTC student account. o If you have questions regarding Financial Aid, please visit the Financial Aid Office: or at (920) Submit two (2) copies of your passport. Apply for passport* immediately if you do not already have one. Go to: for more information. *Passport processing (if needed) can take up to 8 weeks. If you are applying for the Study Abroad Scholarship (current students only) Submit Study Abroad Scholarship Form and include a one (1) page essay that explains 1) why the participant wishes to take part in the two-week program?, 2) how the program will relate to their personal and/or career goals?, and 3) what their expectations are?, and anything else they would like to include. Submit a FVTC transcript (can be unofficial) with your Study Abroad Scholarship application. Keep this Checklist for your Records 1

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3 International Professional Field Study or Language Immersion Program General Application Student ID Today s Date Study Abroad Location Name as it appears on your passport : (name must match exactly as it will appear on your passport)* first middle last Permanent Address: Local Address: Street City State Zip Code Street City State Zip Code Address: Telephone: ( ) Social Security Number: Age: Date of Birth: Program: Passport Number: Cumulative GPA (program students only): Passport expiration Date: Citizenship: US Other: (please specify) Are you applying for Financial Aid? If yes, what type? For questions regarding Financial Aid please contact the Financial Aid Office: or at (920) Name and Address of Parent or Guardian, if applicable: Name: Telephone: ( ) Address: Street City State Zip Code List two (2) Emergency Contacts Below: Name Address Telephone Relationship *All applicants subject to a background check. Applications can be rejected pending background check and under the discretion of the faculty leader. Signature of Student Date Signature of FVTC Representative Date 3

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5 FOX VALLEY TECHNICAL COLLEGE RELEASE, WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT FOR COLLEGE TRAVEL ABROAD PROGRAMS This Release, Waiver of Liability and Hold Harmless Agreement is executed by Valley Technical College (the College ). ( Participant ), and is issued to Fox Study Abroad PROGRAM NAME: PROGRAM DESTINATION: PROGRAM DATES: 1. Participant s desire to participate in the Program. Participant acknowledges that he/she is a student/employee and/or friend who wish to participate in the International Professional Field Study Course or Language Immersion Program ( Program ) for (fill in area of study). The dates of the Program are. Participant expressly acknowledges that he/she has freely and voluntarily decided to participate in this Program. 2. Risks of study abroad. Participant acknowledges and understands that participation in the Program involves risks not found in domestic travel. These include risks involved in traveling to and within, and returning from, one or more foreign countries; foreign political, legal, social, and economic conditions; different standards of design, safety and maintenance of buildings, public places and conveyances; local medical and weather conditions; and other matters related to foreign travel. Participant acknowledges that he/she has made his/her own investigation and is willing to accept these risks. 3. Institutional Arrangements. Participant understands and acknowledges that neither the College, nor the Program s Coordinator, represents, or acts, as an agent for, and cannot control the acts or omissions of, any host institution, host family, transportation carrier, hotel, tour organizer or other provider of goods or services involved in the Program. Participant understands and acknowledges that neither the College nor the Program s Coordinator is responsible for matters that are beyond their control. Participant hereby releases the College and the Program s Coordinator from any injury, loss, damage, accident, delay or expense arising out of any such matters. 4. Independent Activity. Participant understands and acknowledges that neither the College, nor the Program s Coordinator, is responsible for any injury or loss that he/she may suffer when he/she travels independently or is otherwise separated or absent from any Program-related activity. 5. Health and Safety. Participant understands and acknowledges that: a. He/She has consulted with a medical doctor with regard to any personal medical needs. Further, Participant represents that there are no health-related reasons or problems which preclude or restrict his/her participation in the Program. b. He/She is aware of all applicable personal medical needs, and has arranged, through insurance or otherwise, to meet any and all needs for payment of medical costs while he/she participates in the Program. c. He/She understands and acknowledges that the College may, but is not obligated to; take any actions it considers to be warranted under the circumstances regarding the Participant s health and safety. Further, Participant agrees to pay all expenses relating thereto and release the College from any liability for any actions taken. 6. Acceptable conduct by Participant. Participant is aware of the behavior expected while participating in the Program. As a guest, there is certain behavior that is unacceptable and could lead to possible disruption or continuation of Participant s participation in the Program. Participant assures the College that he/she shall act in an appropriate manner at all times. If the College, or the Program s Coordinator, finds it necessary to expel Participant from participation in the Program, he/she will be responsible for his/her own expenses and will not receive any refund of Program fees. 7. Legal Problems: Participant acknowledges and understands that should he/she have or develop legal problems during the course of the Program, Participant will attend to the matter personally with participant s own personal funds. Neither the College, nor the Program s Coordinator, is responsible for providing any assistance to Participant under such circumstances. 8. Travel and Accommodation Problems. Participant acknowledges and agrees to accept all responsibility for loss or additional expenses due to delays or other changes related to transportation problems. Participant acknowledges and understands that neither the College, nor the Program s Coordinator, assumes any liability whatsoever for any losses, damage, destruction or theft of Participant s luggage or personal belongings, and Participant represents and warrants that he/she has obtained adequate insurance, or has sufficient funds to replace such belongings and will hold the College, and the Program s Coordinator, harmless there from. Further, Participant acknowledges and understands that in the event Participant becomes detached from the Program group, fails to meet a departure time or become sick or injured, Participant will bear all responsibility to seek out, contact and reach the Program group at its next available destination. Participant shall bear all costs attendant to contact and reach the Program group at its next available destination. 9. College s Rights and Powers. The College reserves the right to cancel, without penalty, the offering and conduct of the Program. Further, the College reserves the right to withdraw any part of the Program, to make any alterations, deletions or modifications in the Program s itinerary, as deemed necessary by the College or by the Program s Coordinator. over... 5

6 10. Waiver of College Liability and Indemnification of the College for Risks and Dangers. As a condition precedent to Participant s participation in the Program, Participant agrees to exercise reasonable care at all times with respect to the safety of Participant s own person and personal property, and with respect to the safety of other Participants and their personal property. Participant understands, however, that there are certain dangers, hazards, and risks inherent in the activities included in the Program. Participant acknowledges that participation in the Program may involve the risk of damage to property, bodily injury, and, in some cases, even death. Neither the College, nor the Program s Coordinator, assumes any responsibility for such personal injuries or property damage. Participant further acknowledges that he/she is at least eighteen (18) years of age, and is competent to sign this document. Accordingly, Participant, for him/herself and the Participant s spouse (if applicable), heirs, assigns, related individuals and related entities, does hereby waive, release, absolve, discharge and agree to hold harmless the College and its Board of Trustees, directors, officers, employees, teachers, agents and insurers, and the Program s Coordinator (collectively, the Released Parties ), from and against any and all rights, claims, demands, causes of action, obligations, suits, liens, damages, or liabilities of any kind and character whatsoever, whether known or unknown, suspected or claimed, which the Participant shall, or may have, in the future against the Released Parties arising out of, based on, related to, or connected with, the Participant s enrollment and participation in the Program. Participant also agrees to indemnify and hold the Released Parties harmless from the payment of any and all judgments, settlements, costs, disbursements and attorneys fees that are associated with the Released Parties having to defend or investigate any claim, action or proceeding of any type whatsoever arising out of the Participant s enrollment or participation in the Program, including, but not limited to, claims for breach of contract, negligence, strict liability, or otherwise. This indemnification obligation and Release, Waiver of Liability and Hold Harmless Agreement does not, however, absolve the Released Parties from any liabilities, damages, costs, disbursements and attorneys fees incurred due to its intentional or reckless conduct. Participant understands that if any fact with respect to which this Release, Waiver of Liability and Hold Harmless Agreement is executed is found hereafter to be other than or different from the fact in that connection now believed by Participant to be true, Participant expressly accepts and assumes the risk of such a possible difference in fact and agrees that this Release, Waiver of Liability and Hold Harmless Agreement shall be and remain effective not withstanding such difference in facts. 11. Governing Law: Forum. Participant agrees that this Release, Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Wisconsin, which shall be the forum for any lawsuits filed under, or incident to, this Release, Waiver of Liability and Hold Harmless Agreement. The terms and provisions of this Release, Waiver of Liability and Hold Harmless Agreement shall be severable, such that if a court of competent jurisdiction holds any term to be illegal, unenforceable, or in conflict with any law governing this Release, Waiver of Liability and Hold Harmless Agreement, the validity of the remaining portions shall not be affected thereby. 12. Other Provisions. a. The Released Parties are granted permission to authorize emergency medical treatment, if necessary, and that such action by the Released Parties will cause them to assume no responsibility for any injury or damage which might arise out of, or in connection with, such emergency medical treatment. b. It is the Participant s express intent that this Release, Waiver of Liability and Hold Harmless Agreement shall bind the members of the Participant s family and spouse (if applicable); and if the Participant is deceased, it shall be deemed as a release, waiver, discharge, and covenant not to sue the Released Parties by the Participant s family and spouse (if applicable), for any matter arising out of Participant s participation in the Program. c. By signing this document, Participant acknowledges and represents that he/she is fully informed of the contents of this Release, Waiver of Liability and Hold Harmless Agreement. By reading it before signing it, and by signing this document as the Participant s own free act and deed, Participant confirms that no oral representations, statements or inducements, apart from those made herein, have been made. THIS RELEASE, WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT REQUIRES YOU TO GIVE UP SUBSTANTIAL LEGAL RIGHTS. PLEASE READ AND UNDERSTAND THIS DOCUMENT BEFORE YOU SIGN IT. Participant signature Date: Signature of Parent/Guardian (under 18) Date: 6

7 Fox Valley Technical College International Professional Field Study Course or Language Immersion Program Medical Agreement and Release Must be signed by Participant. Must Be Signed By Participant s Parent/Guardian If Participant is Under 18. On rare occasions, an emergency will develop which requires medical care, hospitalization, or surgery for a participant. So that such treatment can be administered without delay, we ask that each applicant and each minor applicant s parent or legal guardian sign the following statement authorizing FVTC representative(s) abroad to secure any necessary treatment. Permission for Emergency Treatment In the event of injury or illness of: I/we hereby authorize any representative abroad of FVTC to secure any necessary treatment, including the administration of an anesthetic and surgery. Signature of Participant Signature of Parent/Guardian (under 18) Date Date 7

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9 Fox Valley Technical College International Professional Field Study and Language Immersion Program CANCELLATION POLICY International Professional Field Study and Language Immersion Program (henceforth the Program ) participants must inform the FVTC Global Education and Services Department (henceforth FVTC Global Ed. ), located at 1825 N. Bluemound Dr., Appleton, WI 54912, IN WRITING if they choose to cancel their participation in the program, and accept that the effective date of cancellation is the postmark date on the envelope if the notification is sent via mail, or else it is a date when is received by the designated FVTC Global Ed. staff. Any written notification needs to contain the following: Current date, Participant s FULL LEGAL NAME, Program Name, Program Dates and a reason for Cancellation. Every effort will be made to accommodate substitutions for students who withdraw however, depending on the time of cancellation, FVTC Global Ed. cannot guarantee the airline will allow a passenger name change as we must adhere to the cancellation policy and name change schedules posted by the airline carrier with whom the air tickets are reserved/booked/purchased for the Program. It is to be noted that if a cancellation occurs within a certain deadline where airline penalties apply, such penalties may affect the amount of student s program fee refund. Applicants must understand that in order to ensure proper program planning and execution, FVTC Global Ed. is required to make various advance deposits and payments to reserve airline tickets, accommodations, in-country travel, etc. Applicants must accept that withdrawal from the Program, or failure to pay any outstanding balance on their program feed by deadlines provided on the FVTC International Professional Field Study and Language Immersion Program Application, FVTC Global Education and Services website and other supplemental materials (marketing flyers, correspondence from FVTC Global Ed., etc), will be subject to the following refund and penalty schedule and conditions: Cancellation Notice to FVTC Global Ed. Refund and/or penalty amount 76 or more days prior to program departure date Full refund including $200 deposit 75 to 60 days prior to program departure date 59 to 45 days prior to program departure date 44 to 31 days prior to program departure date Full refund less $200 deposit, and any applicable airline reservation fees and in-country deposits Full refund less $200 deposit plus $350, and any applicable airline reservation fees and in-country deposits Full refund less $200 deposit plus $500, and any applicable airline reservation fees and in-country payments 30 and fewer days prior to program departure date Program participant owes the full program fee for the entire trip Should the Cancellation notice be received AFTER FVTC GLOBAL ED. paid their vendor(s) for the program, and BEFORE student paid their full program fee, the student understands that unless this fee can be recovered by FVTC Global Ed., he or she is responsible for such payment and will be duly billed for it by FVTC. Additional cancellation charges by apply depending on the cancellation penalties imposed on FVTC Global Ed. by Program-associated vendors and suppliers. Once the Program resumes, no refunds will be made for any unused services, voluntary modifications, no shows or trip interruptions (unless specified below). Exclusions to the above refund and penalty schedule: Students and faculty enrolled in any FVTC Global Ed. Program accept that FVTC Global Ed. reserves the right, at any time and without liability or cost therefore, to cancel the program. If the Program is cancelled by FVTC Global Ed. prior to Program departure date, participants enrolled in the Program at the time such a decision is made will receive a full refund, less any penalties and cancellation charges assessed by air carriers and in-country vendors and suppliers. If the Program while conducted in the host country is cancelled by FVTC Global Ed.* upon recommendation by various sources, no refunds to participants should be expected. However, refunds will be aggressively negotiated on behalf of the Program participants. Participants, who withdraw voluntarily prior to any decision to cancel the Program by FVTC Global Ed., are subject to the cancellation and refund policy above. Also, students who contracted or suffers from serious or life-threatening disease, or who sustains life-threatening injury in the period of time prior to the Program departure date, and which disease or injury precludes the student from fully physically or mentally participating in the Program, is required to supply relevant medical documentation proving the reason why such attendance is not possible to the extend expected by the Program guidelines. Such medical documentation must be delivered to the FVTC Global Ed. staff at the above address, after initial delivery of information by student/student s closest relatives/student s emergency contact as specified in the student s program application, via telephone or as soon as such condition has been determined, but within 5 days at the latest. *Circumstances which will be considered by FVTC Global Ed. as reasons to suspend or cancel the Program prior to, and while it is being conducted in the host country, are the following: Declaration of war by the United States against the host country or an adjacent neighbor; Declaration of war by a third country against the host country; Significant terrorist activity in the program city, region or country; Inability of the Lead Instructor on in-country partner to organize and carry out an academic program; Widespread disruption of public utilities or services in the host country; Widespread civil unrest, violence and/or rioting in the program city, region or country; A declaration of martial law in the host city; region or country; Strong recommendations to cancel the Program made by the in-country partner; Travel warnings and/or specific directive by the U.S. Department of State and/or U.S. Embassy/U.S. Consulate located in the host country. Signature of Student Date *By signing this document, student agrees to, and understands the cancellation policy for all international professional field study and language immersion programs. A copy of this signed document will be given to student upon submission. 9

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11 International Professional Field Study or Language Immersion Program Participant Profile Last Name First Name Middle Study Abroad Location Student ID Number Gender Male Female Age Field of Study I prefer a single room. (increased cost) Yes No I smoke Yes No I would prefer to stay in a non-smoking home Yes No I am a vegetarian Yes No I take regular medications Yes No List any allergies or other medical conditions: Other comments: Write brief comments on the topics below. Travel Experience: Program Expectations: Language(s) studied and/or spoken: How did you find out about the program? 11

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13 International Professional Field Study Course or Language Immersion Program Faculty Recommendation for a Student (Participant Name) is applying for an International Professional Field Study Course or Language Immersion Program. Please indicate below your evaluation of this student/participant: Excellent Good Poor Unable to Judge A. Probable academic success B. Dependability C. Maturity D. Ability to get along with others E. Adaptability to a new environment F. Independence G. Trustworthiness H. Open-mindedness I. Social contact J. Sense of humor K. Good ambassador from your college/united States Please comment on the student/participant s ability to do academic work abroad and to adjust to living in a foreign environment. Signature of Faculty Member Division/Department Date Please return this form as soon as possible to: Aaron M. Gorenc Fox Valley Technical College Global Education and Services 1825 N. Bluemound Drive Appleton, WI Phone: (920) gorenc@fvtc.edu 13

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15 International Professional Field Study Course or Language Immersion Program Faculty Recommendation for a Student (Participant Name) is applying for an International Professional Field Study Course or Language Immersion Program. Please indicate below your evaluation of this student/participant: Excellent Good Poor Unable to Judge A. Probable academic success B. Dependability C. Maturity D. Ability to get along with others E. Adaptability to a new environment F. Independence G. Trustworthiness H. Open-mindedness I. Social contact J. Sense of humor K. Good ambassador from your college/united States Please comment on the student/participant s ability to do academic work abroad and to adjust to living in a foreign environment. Signature of Faculty Member Division/Department Date Please return this form as soon as possible to: Aaron M. Gorenc Fox Valley Technical College Global Education and Services 1825 N. Bluemound Drive Appleton, WI Phone: (920) gorenc@fvtc.edu 15

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17 International Professional Field Study Course or Language Immersion Program Eligibility Requirements: Study Abroad Scholarship Application 1. Applicant must be a U.S. citizen (or legal permanent resident) pursuing a Fox Valley Technical College Associate s Degree, Technical Diploma, Certificate or Apprenticeship program. 2. Applicant must be registered for a Fox Valley Technical College sponsored study abroad program. 3. Applicant must have submitted their general application including the $200 deposit. 4. Applicant has not received the FVTC Global Ed. Study Abroad Scholarship in the past. To apply for a scholarship: (all 3 items must be completed and submitted to be considered) 1. Complete the following: Name: Address: Study Abroad Program Location: Signature: Date: 2. Write a one (1) page typewritten essay on 1). Why you wish to participate in an International Professional Field Study or Language Immersion program, 2). How the program relates to your personal and professional goals, and 3). What your expectations are and any additional comments you wish to include. 3. Attach a Fox Valley Technical College transcript (can be unofficial) to this application. Study Abroad Scholarship winners will be determined by a team of four (4) based on the applicant s one (1) page essay, academic standing and financial needs. Please attach your one (1) page essay and FVTC transcript to this application and submit to: Aaron M. Gorenc Fox Valley Technical College Global Education and Services Room G N. Bluemound Drive Appleton, WI Phone: (920) gorenc@fvtc.edu 17