STUDENT INFORMATION SHEET Guatemala Summer Program 2013 (Please fill out form completely) I. EMERGENCY CONTACT

Transcription

1 STUDENT INFORMATION SHEET Guatemala Summer Program 2013 (Please fill out form completely) Last Name: McGeorge Student ID: First Name: Local Address: City: State: Zip: Local Phone: Address: Gender: Female Male I. EMERGENCY CONTACT Who should we contact in case of an emergency? (Indicate one or more persons below) Name: Address: Phone / Last Name Middle I. First Name Relationship Street City State Zip Code Home Phone Work Phone Cell II. SCHOLARSHIPS/FINANCIAL AID Do you plan to use a scholarship to study abroad? Are you currently eligible for and/or receiving a Federal Pell Grant? Do you plan to apply for additional funding for study abroad? Please specify which scholarship: 1 P age

2 III. MEDICAL DISCLOSURE It is important for the program director to be aware of any medical conditions, disabilities or other special conditions that may need to be accommodated during the program. Please answer the following questions as completely as possible. 1. Do you have any physical or emotional problems that might cause you difficulty with travel, change of location, or increased physical activity? If so, please indicate: 2. Do you have any dietary restrictions, allergies and/or other medical conditions? If so, please indicate: 3. To your knowledge, are there any predisposing medical, surgical, or emotional factors that may, under stress or duress during a program adversely affect you and present a need for immediate intervention while abroad? If so, please indicate: 4. Please list any serious illnesses you have had in the past three years. Are you currently being treated for any illness or conditions? If so, please indicate: 5. Do you have any learning disabilities that will require special attention or accommodations in the learning environment? If so, please indicate: IV. MEDICAL INSURANCE Be advised that some U.S.A. insurance coverage is NOT recognized overseas. The insured student normally must pay for medical service at the time medical care is provided, and must fill out a claim form to be returned to the home company for reimbursement. It is imperative for you to know the limits of your coverage and to carry at least one claim form to be signed by the appropriate medical persons abroad to facilitate reimbursement. Unless such coverage is included in a student s separate insurance policy, each student is REQUIRED to purchase the International Student Identity Card (ISIC), which includes insurance coverage for emergency evacuation and repatriation, before he or she goes abroad. NOTE: For students who are currently enrolled in the Pacific McGeorge Anthem BlueCross student health plan, coverage is provided when traveling abroad during the summer, for no additional cost. The undersigned certifies that I have or will purchase prior to departure, health and hospitalization insurance which is applicable in countries other than the United States. Print Name: 2 P age

3 V. PERSONAL LIABILITY INSURANCE Students desiring to obtain personal liability coverage may do so on a local basis, or avail themselves of coverage that your parents may have with their Homeowners Policy. Check with your insurance provider. VI. SAFETY, RESPONSIBLITIES, AND MENTAL HEALTH Safety Students and parents should inform themselves completely about the risks of any study abroad experience. Although we have orientation programs and procedures to deal with emergencies and crisis situations, students are asked to recognize and acknowledge the risks of any experience outside their own culture and to adjust their behavior, dress, and activities to maximize their own and their group s safety. Behavioral Responsibilities As a guest in another country, there are certain behaviors that are considered unacceptable. The undersigned hereby assures the University that s/he shall conduct her/himself in an appropriate manner, which does not infringe upon the customs and mores of the country in which the program is being conducted, nor upon the rights and safety of the undersigned and/or other participants of the program. Behavioral responsibilities shall be applicable during the course of the program both when in the company of other program participants and when the undersigned is physically separated from other program participants. The program administrator retains the sole discretion to remove anyone from the overseas program. Mental Health For your own welfare, we ask that if you have had any emotional or psychological problems, you consult with a mental health professional in this country before you go abroad to discuss the potential stress of study abroad. We want you to be aware that mental health treatment may not be as widely accessible abroad as it is in the United States. I, (name), acknowledge that I have carefully read and understand the above statements. Printed Name: 3 P age

4 VII. CONDITIONS FOR ENROLLMENT: PACIFIC STUDY ABROAD PROGRAMS STUDENT LIABILITY WAIVER SALZBURG 2012 University of the Pacific policy requires that the student/participant in all Pacific-sponsored study abroad programs sign the following responsibility clause. The completion and return of this form is a requirement for participation in all Pacific-sponsored study programs. RELEASE The undersigned, (name), in consideration of, and as a condition to, the acceptance of said student as a participant in the University of the Pacific McGeorge School of Law Summer Program in Salzburg, do hereby release and discharge University of the Pacific, its Board of Regents, its office of International Programs, its agents, affiliates, officers, and employees from all claims, demands or damages which may arise from loss or injury of any nature to the person, or property of the undersigned as a result of participation, while en route, located in another country, or returning from another country or countries in said program and agrees to indemnify and hold harmless said University of the Pacific, its Board of Regents, its office of International Programs, its agents, affiliates, officers, and employees from any and all loss, damage or expense incurred as a result of said participation. Printed Name: VIII. EMERGENCY MEDICAL CARE In the event of injury or illness to the undersigned, I hereby authorize the representative of the University of the Pacific, McGeorge School of Law, at my expense, to secure necessary treatment, including the administration of an anesthetic and surgery, and such medication as may be prescribed. It is further agreed that, if my condition so requires, I may be returned to the United States, at my expense. I understand that the Graduate and International Program office has the right to review all University records pertaining to my academic performance, disciplinary records and student accounts. I also understand that my participation on study abroad will subject me to the rules and regulations of the study abroad program with regard to both personal and academic performance. I certify that the statements I have made on this application are correct and I will notify the Graduate and International Program office immediately if circumstances change which may compromise my successful participation in study abroad. Print Name Signature Date 4 P age

5 IX. PASSPORT INFORMATION No. Exp. Place of Issuance: (For International Programs Office Use Only) Program: Summer GPA: City: Country: University: Program Contact: On-site Contact: Additional Comments: RETURN TO: Pauline Rodriguez Summer Abroad Programs Graduate and International Programs th Avenue Sacramento, CA Toll Free THE.GLOBE Tel Fax P age