Fill - Free fillable 2016studentapplication 2013 Student SA application Summer.pdf PDF form

2016 Summer Application to Study Abroad

Please type or print legibly. Please fill out completely. Please notify the International Initiatives Office

of ANY changes immediately. Please use the information that is on your passport or that you intend to

use on your passport and airline tickets.

First Name:

Last Name:

Middle Name:

Name and location of

the University you

currently attend:

University ID (W#)

CUM. GPA

Freshman Sophomore Junior Senior

Graduate Guest/non-degree seeking

Classification at the time of application:

Your current street

address:

Your current mailing

address:

Name, relationship, &

phone number of your

emergency contact:

Date of Birth:

E-mail Address:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Allergies, special needs,

or pertinent medical

information:

Signature:

Application Date:

Passport #:Citizenship:

Please Note:

The applicant's cumulative GPA must be a 2.0 at the end of the Fall 2015 semester

to remain eligible to attend the Study Abroad program.

Should the cumulative GPA fall below a 2.0 by the end of Fall 2015, it is the student's

responsibility to withdraw before the Study Abroad deadline for a full refund, minus the non-

refundable $100 deposit.

If a student does not withdraw from his or her Study Abroad program after falling below the GPA

requirements, the student will be held responsible for the program cost of their Study Abroad

program, due to payments overseas made in the student's name.

City/State of Birth:

Attach one COLOR

driver's license

or passport sized

photograph here.

More than one

photograph may be

required during the

application process.

Check individual

program requirements.

Meade Hall Room 103, 900 N. Pine St.

Hammond, LA 70402

Phone: 985-549-2135 or Fax: 985-549-3478

Email: studyabroad@southeastern.edu

www.southeastern.edu/studyabroad

Male

Female

Do you have a valid passport?

No Yes

Expiration Date:

Print Form

Page 2 of 7

Program and Cost

Program: Country:

Class Number 1: Class Number 2: (if offered)

Credit

Audit Audit

Credit

Cost of Program:

- $100 non-refundable deposit:

Amount owed before deadline:

Receipt # Paid Controller's Office:

For Office Use:

Important Note:

* Program cost does not include airfare, passport, or visa fees, unless

otherwise noted under individual program guidelines.

* Program cost does not include travel delay, interruption, or cancellation

insurance.

* Insurance provided through the International Student Identification Card

(ISIC) and/or other agencies is basic insurance and the International Initiatives

Office strongly suggests that students obtain a supplementary travel medical

insurance policy to include travel delay and trip interruption or cancellation.

* The International Initiatives Office is not liable for the cost of trips cancelled

by the student or not attended due to unforeseen events, illness, neglect,

failure to obtain cancellation and interruption insurance, or ineligibility on

the part of the student, either before or during the program dates.

* The International Initiatives Office does not require proof of current

immunizations to be submitted to attend Study Abroad programs. However,

it is highly recommended that students check the dates on their shot records

to make sure that shots are up to date, especially Tetanus. The International

Initiatives Office is not responsible for illnesses contracted during trips, and it

is up to the student to take reasonable precautions.

Signature:

I have read and understand the terms above:

You must be a registered Southeastern Louisiana University student to participate in Study Abroad programs.

If you are not currently registered at Southeastern Louisiana University or you are graduating at the end of the semester before your program, you

will need to go to https://www.southeastern.edu/future_students/apply/index.html to begin the admissions process.

Student Initials:

Have you attended a Study Abroad trip with

Southeastern before?

No Yes

If yes, when and where to?

If you have attended a Study Abroad trip with Southeastern before, please indicate which

scholarship(s) you received in the past.

SGA IGDD Charles Redman FLAN Spanish Club

Phi Kappa Phi John V. Coumes None

Other:

Page 3 of 7

Payments, Withdrawals, and Refunds

Space Availability on Programs and the Non-Refundable $100 Deposit:

The number of students that can participate in Study Abroad is limited. Early application with payment of your non-refundable deposit is advised. Approval of your Application

to Participate in Study Abroad and acceptance of your $100 non-refundable deposit will reserve your place in your Study Abroad program. This reservation is made with the

understanding that you are committed to full payment of program costs and full participation in the program as stipulated in this form, program brochures, handbooks, course

syllabi, and other materials.

Submit deposit of $100 to the Controller's Office (made payable to Southeastern) by Thursday, February 18 2016. Bring a copy of the receipt with you to the International Initiatives

Office. The International Initiatives Office will notify you in writing of your approval to participate, ineligibility to participate, or waiting-list status. Space is limited on Study Abroad

programs. If your program choice has reached its limit at the time of application, the $100 non-refundable deposit will reserve your spot on the waiting list and you will be notified.

$______________________________ Balance due at the Controller's Office by Fee Payment deadline, February 18, 2016 at 4:30 pm.

Late applications will be accepted after February 19, 2016 through March 4, 2016 with an additional $250 late-payment fee. Late

applicants will be responsible for full payment of fees at the time of application (including the payment of the $250 late fee).

Documented approved anticipated financial aid and awarded Study Abroad scholarships will be considered payment. In the event that a student's anticipated financial aid becomes

unavailable for any reason, including suspension of awards because of withdrawal from the Study Abroad program, the student will be responsible for all Study Abroad fees indicated

in this form and other program materials.

Note: Students who owe payments to the University will not be eligible to participate in the Study Abroad program until all debts have been cleared, or the Controller's Office

certifies that payment arrangements have been made. Students owing non-Study Abroad payments to the University may be deemed ineligible to receive SGA Study Abroad

scholarships or other scholarships designated for Study Abroad until all such debts have been cleared, or the Controller's Office certifies that payment arrangements have been made.

Signature: Date:

Acceptance of your application and non-refundable deposit does NOT mean approval to participate in the Study Abroad programs.

The International Initiatives Office will notify you in writing of your approval to participate, ineligibility to participate, or waiting-list status after you meet with your Faculty Program

Coordinator to discuss program requirements, course selection, and other aspects of the program. Approval of your Application to Participate in Study Abroad and acceptance of

your $100 non-refundable deposit will reserve your place in your Study Abroad program. This reservation is made with the understanding that you are committed to full payment of

program costs and full participation in the program as stipulated in program brochures, handbooks, and course syllabi and other materials.

Study Abroad program fees may not be viewable on LeoNet until charges are posted at the Controller's Office for the semester the trip will take place. Students will

be held responsible for all program payments by the established February 18, 2016 deadline. Students should pay at the Controller's Office and will be able to view

their credit balance until charges are assessed to their account. Credit card payments may not be made online for Study Abroad, but should be paid at the

Controller's Office.

All students approved to participate in Study Abroad will be responsible for full payment of the program cost. This charge will remain in effect unless the student

submits to the International Initiatives Office, in writing, a request for withdrawal from the program before the withdrawal deadline. Program payments, due dates, and

refunds of program fees will be established as described below.

Page 4 of 7

Please initial next to each stipulation:

1. All program payments must be completed by the fee payment deadline of February 18, 2016. Students who have not

completed payments and have not filed a request for withdrawal in writing by the withdrawal deadline, also February 18, 2016,

to the International Initiatives Office, will be ineligible for credit in their Study Abroad classes.

2. All payments and deposits made by students deemed ineligible to participate will be refunded. All payments

and deposits made

by students for programs that are cancelled will be refunded.

3. Students wishing to withdraw from a Study Abroad program for which they have been approved to participate must do so in

writing. Students whose written withdrawal is received in the International Initiatives Office by February 18, 2016, 4:30 PM,will

receive full refund of payments made, minus the $100 non-refundable deposit.

4. Students are required to book flight arrangements individually unless otherwise noted within the program itinerary or stated

by the faculty coordinator. Students are allowed to arrive early and/or leave later at their own discretion and are responsible for

all arrangements outside the specified program dates. For any program which includes group air transportation, the program will

purchase one round trip ticket per student. If a student wishes to change the date or itinerary of his/her flights, the student is fully

responsible for all fees and charges associated with said changes.

5. NO refunds will be made for withdrawals received in the International Initiatives Office after February 18, 2016. No refunds will

be made for students who withdraw from a program in progress or for students who are scheduled to participate in a program but

fail to attend.

6. In case of withdrawals, Financial Aid and scholarship awards made to cover Study Abroad costs will be suspended. In the event

that a student's anticipated financial aid and/or scholarships become unavailable for any reason, including suspension of awards

because of withdrawal from the Study Abroad program or suspension for disciplinary reasons, the student will be responsible for

all applicable Study Abroad program fees.

7. Cases of documented extenuating circumstances will be considered on a case-by-case basis. The student must submit a formal

Request for Review to the International Initiatives Office. The Request for Review must include a letter from the student explaining

extenuating circumstances, adequate documentation supporting student's claim (medical records, etc.), and other relevant letters

and documents as necessary. Review of circumstances does NOT guarantee a refund of program costs in full or in part.

8. Grades will be established in accordance with Faculty evaluation of students' program participation and academic performance.

Grade appeals will follow the regular established procedures, starting with an appeal to the course instructor.

I have read and understand the statements above and have initialed each statement to that effect:

Student Initials

Signature: Date:

Page 5 of 7

Other Stipulations

Study Abroad programs are available to registered Southeastern students 18 years of age or older and who are in good academic and disciplinary

standing and to responsible persons, 18 years of age or older, who are not registered Southeastern students, but meet a few basic qualifications. These

are general minimum requirements. Specific Study Abroad programs may have additional restrictions, requirements, and prerequisites that must be

met in order to participate. All persons interested in participating in Study Abroad should contact the International Initiatives Office for assistance.

For full approval to participate after the above stipulations have been met, students must have been approved by the program Faculty Coordinator,

completed their full application with payment of a $100 non-refundable deposit, and have turned in the required two letters of recommendation,

a course approval form, and pass a general background check through the Office of Student Conduct. Once these items have been approved, students

will receive a written acceptance letter from the International Initiatives Office, officially allowing them to attend their chosen Study Abroad trip.

I have read and understand the payment, withdrawal, and refund schedules and stipulations contained in this form. The policies contained in this

form have been explained to me by a representative of the International Initiatives Office. I further understand that, if I intend to use Financial Aid as

my method of payment for this program, I am fully responsible for payment to this program as outlined above, in the event that my anticipated Financial

Aid becomes unavailable for any reason.

I hereby affirm that, to the best of my knowledge, all information I provide on this form is complete and accurate. I understand that withholding

information requested or giving false information may make me ineligible for enrollment in Southeastern's Study Abroad programs. It is my intention

to participate in the Southeastern Louisiana University Study Abroad program as outlined above and in other program materials.

FOR OFFICE USE ONLY:

Application taken by (International Initiatives staff): _________________________________________________

Date: ____________________________________ Time: ___________________________________________

Method application was received:

Signature: Date:

Applied in person

Mail

Fax

Email attachment

Representative of Student

Name: _____________________

PH # _______________________

All parts of application are signed, dated, and

initialed. All policies have been explained to

student.

$100 deposit has been received, and the

student has been given a receipt. A colored

copy of the receipt has been made for the

student's folder.

Office of Student Conduct background

check performed.

Application has been reviewed by the

International Initiatives Office staff.

Page 6 of 7

Statement of Student Responsibility

Student Conduct

In all Southeastern Louisiana University Study Abroad programs, students are expected to behave in a mature, responsible manner, and at all times abide by University

regulations and standards embodied in the Southeastern Louisiana University Student Code of Conduct and other relevant sections of the Student Handbook (accessible at

https://www.southeastern.edu/admin/stu_affairs/handbook/). Directors, and/or faculty leaders have the authority, in compliance with the discipline process outlined in the Student

Code of Conduct, to separate from the group at any time a student who is following a course of action or behavior harmful to the student, to others, or to the program, including

violation of Southeastern Louisiana University rules and regulations. In such a case, no refunds will be issued from Southeastern Louisiana University, and parents will be notified of the

misconduct. All return transportation costs in such circumstances are the responsibility of individual students.

Southeastern Louisiana University does not condone and strives to prohibit the unlawful possession, use, distribution, or manufacture of illicit drugs and alcohol by students

on its property or as part of any of its programs. Southeastern Louisiana University strives to provide a safe, productive, healthy, and supportive environment for students, faculty,

staff, and guests. Recognizing that the abuse of alcohol and other drug use is a major societal concern and health problem, Southeastern sets forth its Drug and Alcohol Policy to

guide community members in making knowledgeable choices which foster ethical, healthy, and responsible lifetime behaviors.

Southeastern Louisiana University will impose disciplinary sanctions on students for violations of its standards of conduct. These sanctions may include, but not be limited

to, verbal and written warnings, loss of certain privileges, fines, and/or separation from University groups.

Student Liability

Southeastern Louisiana University hereinafter referred to as Southeastern and its agents, directors, and officers, act only as agents in arrangements made for this program. Neither

Southeastern nor its agents, directors, or officers shall be liable for any injury, death of persons, loss, damage or accident, delays or expenses arising from Acts of God, dangerous

incident on land or sea, fire, breakdowns of machinery or equipment, acts of government or other authorities, wars, civil disturbances, strikes, riots, thefts, pilferage, epidemics,

quarantines, changes in itinerary, weather, sickness, or from any act of omission of any individual, firm or corporation furnishing transportation, sightseeing, hotel accommodations,

or any other services in connection with the tours, site visits, or other activities related to Southeastern's Study Abroad programs. The right is reserved to amend the advertised

itinerary whenever transportation schedules or other factors make this necessary or advisable.

Signature: Date:

Background Check Policy

For the safety and comfort of all travellers who attend our programs, all Southeastern Louisiana University students who intend to participate in a Study Abroad program will be

required to pass a disciplinary and criminal background check through the Office of Student Conduct and the University Police Department to be eligible to attend their chosen

Study Abroad program.

The International Initiatives Office reserves the right to deny acceptance to Southeastern Louisiana University students

who have problematic disciplinary histories.

Those found ineligible to participate before the payment deadline of February 18, 2016, will be given a full refund, including the deposit. However, no refunds will be

given to those removed from their program for disciplinary reasons after the payment deadline or while overseas.

By signing below, I consent to the release of information from the Office of Student Conduct and the University Police Department and understand the background

check policy.

Release and Assumption of Risk Form

In consideration of my being permitted to participate as a student in a Study Abroad program administered by Southeastern Louisiana University, I do

hereby release Southeastern Louisiana University from liability and assume the risk as follows:

Medical Emergency

I understand that on rare occasions an emergency may develop while I am overseas on a Southeastern Louisiana University Study Abroad program which

necessitates the administration of medical care, hospitalization, or surgery. Therefore, in the event of injury or illness and if I am unable to grant permission

at the time emergency treatment is required, I hereby authorize Southeastern Louisiana University by and through its authorized representative(s) or

agent(s) in charge of said program, to secure any necessary treatment including the administration of an anesthetic and surgery. It is understood that such

treatment shall be solely at my expense and I agree to reimburse Southeastern Louisiana University for any expenses which it might suffer on account of

said injury or treatment thereof.

Indemnification

I agree to indemnify and hold harmless Southeastern Louisiana University and its representative(s) and agent(s) from any and all claims and causes of action

for damage to or loss of property, personal illness or injury, or death arising out of travel or activity conducted by or under the control of Southeastern

Louisiana University with regard to the aforesaid program.

Rules of Conduct

I understand that as a participant in this Study Abroad program, I am subject to the laws of the country where I am studying. I also understand that it is my

responsibility to be informed about the laws of that country and to conduct myself in a manner that complies with those laws. The Director of International

Initiatives shall not, under any circumstances, be responsible for any illegal activities that I may engage in. I further agree to abide by the policies of the

program. I understand that the Program Coordinator has the authority to discontinue my participation in the program, if in the judgement of the Program

Coordinator, my conduct is unacceptable.

Withdrawal from Program

I further understand that I am solely responsible for any and all costs arising out of my own voluntary or involuntary withdrawal from the program prior to

its completion, including withdrawal caused by illness or disciplinary action by Southeastern Louisiana University or its representative(s). In the event that

Southeastern Louisiana University has committed expenses on my behalf prior to the start of the program, I understand that these funds may not be

refundable.

This _______ day of ________________________, 20 ____. I have read and understand the above provisions and agree to be bound thereby.

Day Month Year

__________________________________________________________________________________________________________________

Participant Signature

Page 7 of 7

Revised 8/27/2015

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