Title Mr Mrs Ms Miss Other Gender: Male Female. Mobile No. Date of Birth Day Month Year. Suburb/Town State Postcode

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1 LEARNING ABROAD SHORT TERM PROGRAM STUDENT APPLICATION AND UNIT ENROLMENT FORM Note: Mac users open this document in Adobe Reader as 'preview software' is not compatible. Please contact ITSC on 6000 or print/scan 1. SHORT TERM PROGRAM DETAILS Program Destination 2. PERSONAL DETAILS Please tick as appropriate: Title Mr Mrs Ms Miss Other Gender: Male Female X Family First s Student ID Mobile No. of Birth Day Month Year Address PO Box or Street Address Suburb/Town State Postcode Passport Passport Are you an Australian citizen, Or Permanent Humanitarian visa holder? Or Expiry Please provide copy of the ID Page of your passport with this application Are you an International Student? Do you have Dual Citizenship? of another country? If yes, which Country If you will require a letter for Centrelink confirming your Program details (if selected) please provide your Centrelink Reference (CRN) 3. NEXT OF KIN/EMERGENCY CONTACT DETAILS (THIS MUST BE A FAMILY MEMBER) PO Box or Street Address Telephone Country Code Area Code Suburb/Town State Postcode Relationship to you Country Learning Abroad Short Term Program Student Application & Unit Enrolment Form updated 23/08/2017 1

2 4. PERSONAL STATEMENTS In 100 words or less, describe: 1) why you should be chosen to participate in this program; and 2) what benefits you will gain from participation in the program. 5. ECU COURSE INFORMATION & PROGRAM UNIT Current ECU Course: Major area of study: PROGRAM UNIT ECU credit is available for overseas Short Term Programs. Please note that the normal unit fees apply and that the Short Term Program costs do not include unit fees. In order to receive credit towards your ECU degree for the overseas Short Term Program, please ensure that you supply correct Unit information. If you are unsure whether or not you are eligible to enrol in the Program unit, please contact your Course Coordinator to discuss alternative options (e.g. getting credit towards another unit). Note: it is not possible for a student to get credit for a future unit. ECU unit code ECU unit title 6. SPONSORED STUDENTS Are you receiving a scholarship from a private or government body toward your ECU tuition? Yes No If yes, please advise in the space provided (e.g., SACM): 7. DIETARY REQUIREMENTS/MEDICAL INFORMATION Do you have any special dietary requirements while on the program? No Yes Please complete the following list and indicate if you have had or still have any of the conditions below as well as their usual treatment. of last tetanus injection or booster Day Month Year A. Heart problems Yes No B. Respiratory Yes No Asthma Yes No Others Yes No C. Allergies Yes No 1. Food Yes No 2. Drugs Yes No (mild/severe) Learning Abroad Short Term Program Student Application & Unit Enrolment Form updated 23/08/2017 2

3 3. Others Yes No D. Diabetes Yes No E. Epilepsy Yes No F. Phobias Yes No If you answered yes to any of the above, please describe what dietary requirements they are: Do you have any other conditions that the Program Leader should know about or will you be travelling with any medications? Please describe: 8. SPECIAL ASSISTANCE Will you require any special assistance while on the program? Yes No If you answered yes, please provide the details: 9. EXPECTED STUDENT BEHAVIOUR AND CONDITIONS Program participants are expected to; read the Australian Government Department of Foreign Affairs and Trade s travel advice on their website for the program destination country/ies prior to departure; register with your country s diplomatic mission if you are not a citizen or permanent resident of Australia. read the advice given by the Travel Doctor in the Travel Health Advisory Report for the program destination country/ies prior to departure; and show respect for the host country s culture and customs and those of fellow program participants. By participating in this Short Term Program, students agree to the following conditions: CODE OF CONDUCT 1. As an enrolled student at ECU, I will continue to abide by the relevant ECU Statutes, Rules and Policies during the Program. I understand that ECU may take disciplinary action, including withdrawing my participation from the Program, for any violation of any applicable ECU Statutes, Rules or Policies or for conduct that could bring ECU into disrepute. 2. I acknowledge I am subject to the laws of the country to which I travel to on the Program and it is my responsibility to familiarise myself with, and understand the details of, these laws and obey these laws while in the country. FINANCIAL 3. I acknowledge that Edith Cowan University ( ECU ) acts only in the capacity of agent for me when planning the Program. ECU does not itself provide the transport, accommodation, meals or other facilities for the Program (collectively the Services ), all of which are provided by air carriers, land carriers, cruise operators, hoteliers or other service providers ( Providers ). 4. I acknowledge that where ECU makes a booking requested by me, it does so on my behalf on the terms and conditions set out with the Provider(s) offering the Services. All tickets or vouchers issued are subject to all tariffs, terms and conditions contained in the contracts in use by the Provider(s) and constitute a contract between the Provider(s) and myself (or the person having the benefit of the Services). By making a booking, I agree to be bound by such contract(s). 5. ECU reserves the right to substitute Services for the Program or to change the Program Leaders, itinerary or travel arrangements if ECU believes it to be in the best interests of all the Program participants. Learning Abroad Short Term Program Student Application & Unit Enrolment Form 3

4 6. Participation in the Program is subject to confirmation that your application has been approved by ECU. In addition, ECU and its appointed Program Leaders may at their discretion ask you to leave the Program group if you refuse to follow reasonable instructions of the Program Leader. Any applicable refund will not include payments or cancellation charges for any bookings for private or additional travel or services made extra to the published Program; these are your responsibility. HEALTH, SAFETY AND SECURITY 7. I am responsible for disclosing any pre-existing medical condition, which may require additional support, to ECU prior to departure and while participating in the Program. 8. I am responsible for taking reasonable measures to prevent/ameliorate exacerbation of pre-existing health conditions. This includes carrying suitable medication and discussing a prevention/action plan with a medical professional in the event of a flare-up. 9. I am responsible for complying with any vaccination requirements or other health requirements for entry into the country which the Program travels to, as advised immigration authorities of the host country. 10. As a participant of the Program I am covered, for the duration of the overseas Short Term Program, by ECU s Corporate Travel Students Policy. I have read the Certificate of Currency for this policy ( and I understand the scope and limitations of the policy. I understand that it is my responsibility to ensure that I am adequately covered for all additional travel and medical insurance, beyond the coverage provided by ECU. ACKNOWLEDGEMENT, RELEASE AND ASSUMPTION OF RISK 11. Subject to the ECU Corporate Travel Students Policy, I hereby release ECU and its employees, servants, agents or contractors from any and all liability for death, disability, personal injury, property damage, property theft and all other foreseeable risks claims or actions of any kind (including breach of contract and negligence) that I may have or may at any time have had arising from or in connection with, directly or indirectly, my participation in the Program. 10. DECLARATION AND CONSENT I declare that the information provided in this application is accurate to the best of my knowledge. I have attached a copy of my valid passport (with at least 6 months left before expiry after the last day of travel) with this application; or I am in the process of applying for a passport. I hereby authorise my enrolment into the nominated ECU unit (if not already enrolled) and will pay the unit fee once advised (where applicable) I understand that the approval of this application will be subject to eligibility checks and a selection process. I agree to complete a survey/feedback and return it the International Office within 7 days of receiving the survey request. I hereby give my consent that images (photographs & videos) of me in regards to this Short Term Program may be reproduced, published and communicated by ECU, for example in publications. If you have previously received a government grant, please provide details here (e.g. NCP, Endeavour) Printed/typed name is not acceptable Day Month Year 11. SOURCE OF INFORMATION For marketing purposes, what was your main source of information for finding out about this program? (Circle only one) Posters/Flyers Student Portal Website Lecturer Class Presentation Other: Please submit the completed and signed Form together with a copy of your valid passport ID page for processing to: international.office@ecu.edu.au. Learning Abroad Short Term Program Student Application & Unit Enrolment Form 4

5 OFFICE USE ONLY PROGRAM/PROGRAM LEADER APPROVAL PLEASE PROVIDE REASONS IF CRITERIA HAS NOT BEEN MET BY STUDENT PROGRAM CREDIT APPROVAL COURSE COORDINATOR APPROVAL By signing below you approve this student, on successful completion of the program, to receive full or partial credit for the unit indicated on page 2 Section 5. ADDITIONAL PROGRAM CREDIT APPROVAL (if required) ASSOCIATE DEAN: TEACHING AND LEARNING In the rare instance where a student does not fulfil the Program study unit requirements, the AD (T&L) will be required to provide additional approval. Learning Abroad Short Term Program Student Application & Unit Enrolment Form 5