Application for Audencia Winter Intersession November and December 2014 (field trip and workshop), January 2015 (abroad)

Transcription

1 Application for Audencia Winter Intersession November and December 2014 (field trip and workshop), January 2015 (abroad) 1. Name Last Name, First Name Middle Initial 2. Student ID # 3. Address (mandatory) 4. Application for Audencia Nantes School of Management Nantes France University City Country 5. Passport (Issuing Country & Number) Expiration Expected date of receipt if passport is pending: 6. Academic Major Concentration: 7. Current Address Number & Street or Box No. City State Zip Cell Telephone ( ) Other telephone ( ) 8. Permanent Address Number & Street or Box No. City State Zip Home Telephone ( ) 9. Class Level immediately prior to departure (Check one box) Freshman (0-29 semester units) Sophomore (30-59 semester units) Junior ( /2 semester units) Senior (90 or more semester units) 10. Cumulative Grade Point Average (GPA = Grade Points Units Attempted): 11. Sex: Male Female 12. Birth Date 13. Age Mo/Day/Year 14. Birthplace: City, State: Country: 15. Citizenship 16. State of California residence status for campus registration fee purposes (check one) CA resident Non-Resident F-1 Visa Student* *For visa questions please contact kmorrissey@fullerton.edu I would like to receive information about scholarships (funded by other than the Business Honors program) I hereby submit my application to participate in one of the California State University Fullerton Study Abroad Program to Nantes, France. I certify that the information given in the application is true and complete and that I understood each question. Submit application to: Kathryn Morrissey UH-244 (Study Abroad office) Signature of Applicant Date

2 Permission for Emergency Treatment Date: To Whom It May Concern: The Director of the International Exchange Program for (Name of Overseas University): Audencia Nantes School of Management in (Country): France has my authorization to act on my behalf in the event that, (Name of Participant): requires emergency medical care while participating in the Cal State Fullerton Exchange Program from (program dates): to. If the student is 18 years of age or older: Student s Signature: If the student is under 18 years of age: Signature of Parent / Guardian: In Case of Emergency Contact Person: Relationship to Participant: Street Address City: State: Zip: Home Telephone: Message Number: Cal State Fullerton Contact Kathryn Morrissey, Study Abroad Advisor Office of International Education and Exchange Cal State Fullerton, UH-244 Fullerton, CA Tel: 657/ Fax: 657/ sabroad@fullerton.edu

3 Name of Study Abroad Program: Audencia Nantes School of Management Term Abroad: Winter Intersession I understand that during the period of my study abroad Program, I am a Print name guest in England, France, Germany, and Belgium Location(s). I also understand that: While living in _ England, France, Germany, Belgium I will be subject to the laws of that country. Location(s) My behavior reflects upon my country and my university. I agree to conform to standards of conduct consistent with the maintenance of the reputation of the Host University, and CSUF. England, France, Germany, Belgium is more formal than the USA in dress, in speech and in social relationships, and while there, I will act according to local socially acceptable, polite norms. Attendance is required in all regularly scheduled classes, field trips, and other group activities. My grade(s) can be affected by excessive absences. I am responsible for registering at the host institution as required and for contacting the Study Abroad office at CSUF to guarantee I am registered for placeholder course (s) as needed at CSUF. I understand grades for courses are awarded by the course instructors on the basis of their evaluation of my scholastic achievement. Letter grades (A, A-, B+, etc) will be recorded on my transcript. Grades received in programs sponsored by other approved institutions will be accepted from the sponsoring institution, on a pre-approved basis (in consultation with my academic advisor). I am considered a student of California State University, Fullerton and therefore I shall abide by the Dean of Student s JUDICIAL AFFAIRS policies as set forth on their website ( including, but not limited to: Title V, Alcohol & Drug Use; drug-free school Information; Nondiscrimination Policy; Plagiarism; Sexual Harassment; Student Discipline Procedures; Student Rights & Responsibilities; Academic Appeals Procedures; and Academic Dishonesty and Repetition of Courses. I am aware that I could be asked to return home, at my expense, if I am in violation of these policies. I have read, received, understand and agree to the above. Print Name: Date: Signature: Deposit required with application: $400 Funds will be applied toward program expenses. Complete section III of the deposit form attached. Deliver check and form to the University Cashier. Submit a copy of the deposit receipt with your completed application. Refund Policy: 100% refund for withdrawal before July 25 $150 cancellation fee for withdrawal between July 25 and September 24 $200 cancellation fee for withdrawal between September 25 and November 14. Full payment required by November 15. No deposit refunded thereafter.

4 CSU FULLERTON- RELEASE OF LIABILITY PROMISE NOT TO SUE, ASSUMPTION OF RISK AND AGREEMENT TO PAY CLAIMS Activity: Study Abroad Activity Location(s): Nantes, France Activity Date(s) and Time(s): December 2014 to January 2015 In consideration for being allowed to participate in this Activity, on behalf of myself and my next of kin, heirs and representatives, I release from all liability and promise not to sue the State of California; the Trustees of The California State University; California State University, Fullerton and their employees, officers, directors, volunteers and agents (collectively University ) from any and all claims, including claims of the University s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss I may suffer because of my participation in this Activity, including travel to, from and during the Activity. I am voluntarily participating in this Activity. I am aware of the risks associated with traveling to/from and participating in this Activity, which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and/or death. I understand that these injuries or outcomes may arise from my own or other s actions, inaction, or negligence; conditions related to travel; or the condition of the Activity location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my participation in this Activity, including travel to, from and during the Activity. I agree to hold the University harmless from any and all claims, including attorney s fees or damage to my personal property, that may occur as a result of my participation in this Activity, including travel to, from and during the Activity. If the University incurs any of these types of expenses, I agree to reimburse the University. If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. I am 18 years or older. I understand the legal consequences of signing this document, including (a) releasing the University from all liability, (b) promising not to sue the University, (c) and assuming all risks of participating in this Activity, including travel to, from and during the Activity. I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me. Participant Signature: Participant Name (print): Date: If Participant is under 18 years of age: I am the parent or legal guardian of the Participant. I understand the legal consequences of signing this document, including (a) releasing the University from all liability on my and the Participant s behalf, (b) promising not to sue on my and the Participant s behalf, (c) and assuming all risks of the Participant s participation in this Activity, including travel to, from and during the Activity. I allow Participant to participate in this Activity. I understand that I am responsible for the obligations and acts of Participant as described in this document. I agree to be bound by the terms of this document. I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me. Signature of Minor Participant s Parent/Guardian Minor Participant s Name Name of Minor Participant s Parent/Guardian (print) Date

5 REIMBURSEMENT OR DEPOSIT TO UNIVERSITY ACCOUNT Complete this form and take it to the Student Financial Services/University Cashier at UH 180 with your deposit check of $400. The date and time you make your deposit determines your scholarship priority. Date To: CSUF Cashier From: CWID: Department: Business Honors Study Abroad Please make the following deposit: Check # Dated Amount $ Cash Amount $ Deposit to Item Code S2310 AUDENCIA School of Management Chartfield: 2 l 5 l 0 l 8 l 8 l 1 l T l H l E l F l D l Account Fund THE CALIFORNIA STATE UNIVERSITY Bakersfield / Channel Islands / Chico / Dominguez Hills / East Bay / Fresno / Fullerton / Humboldt / Long Beach / Los Angeles / Maritime Academy Monterey Bay / Northridge / Pomona / Sacramento / San Bernardino / San Diego / San Francisco / San Jose / San Luis Obispo / San Marcos / Sonoma / Stanislaus