Rev. 8/14
Buena Vista University
Interim Travel Course Application
Personal Information:
Name______________________________DOB__________________ID #_________________
Gender: ___Male ___Female Circle one: 1
st
year 2
nd
year 3
rd
year 4
th
year 5
th
year
Citizenship: __USA __Other (please specify_________) Do you have a valid passport? Yes No
Campus Address:_______________________________________________________________
Campus Telephone:__________ Major____________________________ CGPA____________
Permanent Address: ____________________________________________________________
_____________________________________________________________________________
Course Information:
Time of Travel: Interim _____ May ______
Travel Course Destination: ____________________________________________________
Medical Release:
Because travel can be quite rigorous and demanding, we believe that only those students who are in good
physical and mental health should plan to participate. For that reason, we ask that the student (or his/her
parent/guardian if the student is under the age of 18) carefully read, then sign and date the following
certification.
“I certify that I am in good physical and mental health and that I do not suffer from any special conditions
which would prevent me from successfully taking part in the travel study course noted above. I further
understand that, in the event of an emergency, BVU, or its representative(s), reserves the right to arrange
medical treatment and/or notify my parent(s) or legal guardian for same. Further, I affirm that I will truthfully
and fully complete the medical information form required by the university.”
_________________________ ______________________________ ____________________
Name (please print) Student/Parent Signature Date
Rev. 8/14
Emergency Contact Information:
Please list two names of people we may contact in the case of an emergency. We will contact the first name
listed unless they are unavailable and we will then attempt to contact the second contact person. Please print
clearly.
Name: _______________________________________ Relationship:_____________________
Address: _____________________________________________________________________
Telephone (with area code): ______________________________________________________
Name:_______________________________________ Relationship:_____________________
Address: _____________________________________________________________________
Telephone (with area code): ______________________________________________________
Advisor’s Recommendation
As this student’s advisor, I ____endorse ____do not endorse his/her desire to enroll in the above mentioned
travel course.
______________________________ _______________________ _________________
Advisor’s name (please print) Advisor’s signature Date
Disciplinary Status
As of the date of my signature, this student has not and does not have any disciplinary action taken via
procedures outlined in the Student Handbook.
___________________________________________ ________________
Assistant Dean of Students Signature Date
Submit completed application form to the Associate Dean of Faculty’s Office - Dixon Eilers 107
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