Fillable CGE International Exchange Visiting Student Application Master (Lock Haven University)

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CGE International Exchange Visiting Student Application Master (Lock Haven University)

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The CGE International Exchange Visiting Student Application Master (Lock Haven University) form is 17 pages long and contains:

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  • 48 check-boxes
  • 181 other fields

Country of origin: US
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200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 1
All international exchange and visiting students must be nominated by their home institution in order apply for
admission to Lock Haven University of Pennsylvania (LHUP). An incomplete application will not be considered.
Application Deadlines: Spring semester: November 1 and fall semester: April 1.
Instructions: The application packet is a fillable Adobe Acrobat PDF. Students must type all fields, print the
document, and scan back as a PDF to submit to John Gradel at jgradel@lockhaven.edu. All forms except the pre-
arrival form are due at the time of application. Hand written and incomplete applications will not be processed.
1. Application Form – complete this form that provides necessary information about you.
2. Academic Planning Form - this form assists us with creating your student class schedule. You should
complete this with your academic advisor/professor/tutor. Please list all classes taken at your home
university. The CGE can also accept a copy of your transcript if translated into English.
3. International Exchange Student Registration Form – this form assists us with registering you in
classes. You should complete this with your academic advisor/professor/tutor. Please select up to 10
classes/courses you would be interested in taking at LHU. Please note the following important items:
o The course catalog with unit descriptions lists all the possible class/courses that could be taught
at LHUP (http://www.lockhaven.edu/coursecatalog/) – this is not the final fall or spring course
offerings. Students may not be enrolled in their preferred courses as some courses are not
offered every semester, and we will do our best to find acceptable substitutes. The final
schedule is posted after the deadline, so you may have classes in your list that are not offered.
o Students whose first language is not English will be enrolled in one (1) class for a total of three (3)
credits: English Composition for International Students. If English is your first language, you will be not
be placed into English Composition for International Students unless requested on your form.
o Students will be registered for four (4) classes for a total of twelve (12) credits which is a typical workload
for students studying in the United States. One (1) of the classes is listed above leaving three (3) to
choose. If your first language is English, you will be placed in four (4) different classes.
o If you need to enroll in 15 credits for a total of 5 classes, please indicate on the application.
o Not all “1
st
choice” classes can be accommodated as the class may not be taught that semester. Please
select ten (10) different classes within the 100-200 level range.
4. Immigration Document (F-1 Visa: Form I-20 or J-1 Visa: DS-2019) Application– these forms
provide information needed to provide you with the correct immigration documents to apply for a student
visa. Proving you have sufficient financial support to attend LHU is required, so supporting proof of financial
documents should also be attached to this application.
5. Residence Life Roommate Selection Form - this form assists with selecting your room.
6. Health Services History Form – this form is required to ensure you have the correct immunizations and to
provide Health Services with your health history should you need medical assistance.
7. Copy of Passport – Please attach a scanned copy of your passport photo page with biographical information
(name, country, place of birth, etc.). This is required to receive immigration documents.
8. English Language Proficiency Requirement: Please attach a scanned copy of scores from an English
Proficiency exam (see last page for accepted scores) or a letter stating you are proficient in the English
language (countries where English is not the first language). This will be necessary to be issued a visa.
Any questions should be directed to John Gradel at jgradel@lockhaven.edu
regarding the international student exchange and visiting application.
International
Exchange & Visiting
Student Application
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 2
INTERNATIONAL STUDENT EXCHANGE & VISITING APPLICATION FORM
Name: Family/Surname ______________________________________________________________________
First ______________________________________ Middle Name (if none, use “X”) _____________________
City of Birth: _______________________________ Country of Birth: _________________________________
Country of Citizenship: _______________________
Plan to study for the semester (insert year): FALL 20___ OR SPRING 20___ OR ACADEMIC YEAR 20____ to 20____
Permanent Address - Home Country:
Address __________________________________________________________________________________
City __________________________________________ State/Province ______________________________
Postal Code____________________ Country Name _______________________________________________
Home Phone # (w/ country code) _____________________ U.S. Phone #_____________________________
Do you have a U.S. based phone #? If not, please check here: __________I do not have a phone # in the U.S.
College/University E-Mail: _____________________________ Personal E-Mail:__________________________
Emergency Contact - Home Country:
Name ____________________________________ Relationship _____________________________________
City __________________________________________ State/Province ______________________________
Postal Code____________________ Country Name _______________________________________________
Home Phone # (with country code if known) _____________________________________________________
E-Mail:____________________________________
I understand and certify that all information I have put into this application packet is accurate to the best of
my knowledge. I also realize that by submitting my information after the deadline, I might not get a priority
housing assignment or class/course selection: (Please Print)
_________________________________________________________________________________________
Last or Family Name First Name
_________________________________________________________________________________________
Signature Date
Center for Global Engagement OFFICE USE ONLY – Please do not write in this space
o Approved o Denied _________________________________ ____________
Signature Date
Student Notified (time and date): __________________________
Comments:
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200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 3
INTERNATIONAL STUDENT EXCHANGE & VISITING ACADEMIC PLANNING FORM
NAME: MAJOR OR INTENDED MAJOR: ___________________________
FIELD OF STUDY: ________________________________________________________
I intend to do the following while at LHU (check all that apply):
¨ Take courses that will count toward degree requirements.
¨ Take courses related to my major for my personal interests.
In the space below, list the TITLES of courses in which you have enrolled prior to attendance at LHU.
If more space is needed please feel free to use back of form or another sheet.
1. _______________________________________________________________________________
2. _______________________________________________________________________________
3. _______________________________________________________________________________
4. _______________________________________________________________________________
5. _______________________________________________________________________________
6. _______________________________________________________________________________
7. _______________________________________________________________________________
8. _______________________________________________________________________________
9. _______________________________________________________________________________
10. _______________________________________________________________________________
11. _______________________________________________________________________________
12. _______________________________________________________________________________
13. _______________________________________________________________________________
14. _______________________________________________________________________________
15. _______________________________________________________________________________
Highest Math Level Achieved (i.e. Algebra II, Trigonometry, Calculus, Linear Functions…) **MUST LIST**
__________________________________________________________________________________
__________________________________________________________________________________
**********************************************************************************
I am aware that course offerings at LHU fluctuate and that it may be necessary to adjust my courses accordingly.
Also, I understand that my major department has final authority over what classes are to be taken at LHU to fulfill
any requirements. I am also conscious that I may need to adjust my schedule once I arrive at LHU.
______________________________________________________________________
Student’s Signature (Month/Day/Year) Date
_________________________________________________________________________________________
Home Institution Advisor’s Signature (Month/Day/Year) Date
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200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 4
INTERNATIONAL STUDENT EXCHANGE & VISITING REGISTRATION FORM
This form is to be used by international exchange and visiting students representing partner universities with which LHU
maintains formal exchange ties. Non-exchange or visiting students interested in seeking a baccalaureate or
graduate degree at LHU must submit a formal application to the Office of Admissions.
Application deadlines can be found on the Center for Global Engagement website under exchange students. Return this
form with the rest of your international exchange application.
PLEASE COMPLETE ALL INFORMATION:
Plan to study for the semester (insert year): FALL 20___ OR SPRING 20___ OR ACADEMIC YEAR 20____ to 20____
Personal Information
Name
Home College/
University
Major Study:
Home Address
Country of Birth
Country of
Citizenship
High School Graduation Date:
High School Name:
Home Phone
Cell/Mobile
Phone
Gender
Married/Single
(optional)
Birthday
(Month/Day/Year)
Personal E-mail
Address
United States Department of Education Questions
What is your
ethnicity?
What is your
race? Mark one or
more races to indicate
what you consider
yourself to be.
Course Choices
If you need help in selecting appropriate courses and alternates, contact your home institution International Office (advisor, tutor, or
professor) or the Center for Global Engagement at Lock Haven University. All courses must be selected from our LHU Course
Catalog:"http://www.lockhaven.edu/coursecatalog/ . It is important that you make different 1
st
and 2
nd
choices. Exchange
students are required to take a minimum of 12 credit hours of courses per semester to retain full-time status;
generally four courses valued at 3 credit hours each. *YOU MUST LIST COURSE NAME AND NUMBER*
1
st
Five Different Choices (Course # & Name)
Ex: COMM100 - Introduction to Communication
2
nd
Five Different Choices (Course # & Name)
Ex: COMM100 - Introduction to Communication
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
Office Use Only LHU Student ID: _____________
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 5
IMMIGRATION DOCUMENT (F-1 VISA: FORM I-20 or J-1 VISA: DS-2019)
APPLICATION FOR EXCHANGE OR VISITING INTERNATIONAL STUDENT
PART 1: Personal Information
1. Name as spelled in your passport:
_________________________________________________________________________________
Family/Last Name First Name Middle Name
Enter your name exactly as shown in your passport.
2. Date of Birth: Month______ Day ______ Year _______
3. Gender: □ Male □ Female (Please check one)
4. Country of Birth: ___________________________________________________
5. Country of Citizenship: ______________________________________________
6. Country of Permanent Residence: ____________________________________
7. City of Birth (as may be noted in your passport): _________________________________________
8. Permanent Address in Home Country
__________________________________________________________________________________
Number and Street
__________________________________________________________________________________
City Province /State/Territory Postal Code
9. Address in the United States (if known)
__________________________________________________________________________________
Number and Street
__________________________________________________________________________________
City Province/State/Territory Postal Code
10. U.S. Telephone #_____________________ Email__________________________________
11. Dependents: A student wishing to have his/her family member(s) accompany him/her must document
the following amounts for each family member per calendar year of study: Spouse: $12,700 per calendar year;
each child: $3,036 per calendar year. If you are bringing your family, please let John know at
jgradel@lockhaven.edu know when you e-mail him regarding estimated costs on the next page.
□ I plan to come without dependents
□ The following dependents will accompany me (list names and relationships):
1. ______________________________________________________________________________________________________
Name (Family/First/Middle) Date of Birth (M/D/Y) Country of Birth
________________________________________________________________________________________________________
Country of Citizenship Gender Relationship to you (Spouse/Child)
2. ______________________________________________________________________________________________________
Name (Family/First/Middle) Date of Birth (M/D/Y) Country of Birth
________________________________________________________________________________________________________
Country of Citizenship Gender Relationship to you (Spouse/Child)
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 6
PART 2:
(If you are in the United States, now, please complete this section. If not, continue to Part 3.)
What is your Immigration Status? You may apply regardless of your immigration status.
□ F-1 or J-1 What is your SEVIS ID number? N________________________________
What is the purpose of your requested Form I-20 or DS-2019? (Check one)
□ School Transfer
□ Change education level or program at Lock Haven University
□ Reinstatement to F-1 Status
□ Another Status: Which one? ___________________
Before we issue your Form I-20 or DS-2019, we want to advise you. Please make an appointment to
see John Gradel (jgradel@lockhaven.edu) in the Center for Global Engagement at LHU.
Do you plan to travel outside the U.S. before school starts?
□ Yes Tell us how you would like to get your Form I-20 or DS-2019 in Part III.
□ No If you are F-1 or J-1, you will receive school transfer or other instructions.
If you hold another status, you must meet with CGE staff before a new Form I-20 or DS-2019
can be issued.
Part 3
If you are NOT in the United States now, complete this section.
DID YOU RECENTLY ATTEND SCHOOL IN THE U.S. IN F-1 or J-1 STUDENT STATUS?
□ NO
□ YES If yes, what was the last date of your attendance? ________________________
(Month/Day/Year)
If you attended a U.S. school last term and traveled home on holiday between academic terms, you
are considered a “School Transfer” and need to have your record transferred to us before your Form
I-20 or DS-2019 may be issued. Please contact your international student advisor at your previous
school immediately to authorize the release of your SEVIS record to us.
RECEIVING YOUR I-20 or DS-2019:
Your Form I-20 or DS-2019 will be sent standard airmail to your home university’s international office
where they will provide you with the immigration documents, along with your acceptance packet
(usually should arrive a month and a half after the deadline).
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 7
PART 4
Student’s Statement of Financial Support
Part 4 must be completed in full and needs supporting documents as noted below.
What level of education will you be pursuing? _______________________________________________
(Visiting or Exchange/Major)
What are your estimated annual costs?
Each exchange or visiting student attending LHU will be billed a different cost. Please e-mail John Gradel at
jgradel@lockhaven.edu to obtain an estimated cost. Please indicate which University you are from, how long
you are studying (semester or year), and if you are going to be an exchange or visiting student. Once you
receive this information, please complete the rest of the form and attach supporting documents.
Total Estimated Cost:
How will you fund for each semester or year of your program of study?
Please check your funding sources below and indicate how much will be provided or available to
you every year:
Source(s) of my support (check all that apply): $ Amount
□ Personal Funds:
The amount available to me from my own resources
_________________
□ Funds from this school:
renewable every semester/year
Type: ____________________________________________________
_________________
□ Cash Funds from a Sponsor:
to be given to me every semester/year
Sponsor’s name: ___________________________________________
_________________
□ Cash Funds from a Sponsor:
to be given to me every semester/year
Sponsor’s name:
___________________________________________ _________________
□ Cash Funds from a Sponsor:
to be given to me every semester/year
Sponsor’s name:
___________________________________________ _________________
Total amount available to me:
This amount must greater than or equal to your minimum annual costs.
The following documents are attached to this application to prove my funding:
(All documents must be attached in the scanned PDF, due at the application deadline.)
My personal documents: Funds from the School:
□
Bank/asset statement
□
Award letter
□
Proof of income/assets
□
Copy of contracts
Cash Sponsor’s documents:
□
Affidavit of Support
□
Proof of Income
□
Bank Statement
"
"
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 8
SPONSOR’S AFFIDAVIT AND EVIDENCE OF ANNUAL CASH SUPPORT
WHAT DOES THIS AFFIDAVIT MEAN?
By completing this affidavit, you are swearing to the U.S government that you will provide this student with a
specific amount of money from your own financial resources
for every semester or year
he or she is going to
study at Lock Haven University and live in the U.S. You are also proving that you can afford the support you
are promising with the documents you have attached.
Before signing it, it is important to understand that you are making a financial commitment to the student
which should not be broken. Sponsors who fail to provide the promised support force students to drop out of
school and cause pain and suffering. Do not expect that the student will be able to help support the costs
through employment. Employment is strictly controlled by the U.S. Department of Homeland Security and very
limited.
HOW TO COMPLETE THIS FORM:
ü Complete this form in English (or have it officially translated). Promise only the amount of money you
are able to give. The most common reason we reject affidavits is that we do not believe a sponsor can
afford to give as much as promised.
ü Sign and date the affidavit.
ü Attach the supporting evidence listed below. The affidavit will not be accepted without the required
supporting evidence. You will need to keep the originals to present at the United States Consulate or
Embassy at the visa interview.
SUPPORTING EVIDENCE REQUIRED FROM YOU OR A SPONSOR:
1. Proof of income (
any of the following
) with most recent pay stub:
ü Investment statements for the last six months,
or
ü Income tax returns or receipts,
or
ü Pay stubs for last six months,
or
2. Bank statement in your name only. A monthly statement of balances and deposits.
ü
If another person’s name appears on your bank statement, that person must complete a separate
affidavit. A letter from a bank officer will not be accepted.
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 9
THIS IS MY SWORN PROMISE OF CASH SUPPORT
I, _____________________________________________, promise that I can and will give
My name
______________________________________________ no less than U.S. $ __________________
Full name of student
in cash for EVERY SEMESTER OR YEAR of the student’s program of study at Lock Haven University.
My relationship to the student is______________________________________________________________
Parent, spouse, brother/sister, friend
My address is:
________________________________________________________________________________________
________________________________________________________________________________________
Telephone _____________________ Fax____________________ Email______________________________
The following persons are fully or partially dependent upon me for their support. (Do not include the student
named above).
_________________________________________________________________________________________
Name Relationship to me Age
_________________________________________________________________________________________
Name Relationship to me Age
Name of my employer: _____________________________________________________________________
Annual salary: _____________________(USD) Other income: _______________________________ (USD)
My proof of income and bank statements are attached: □ Yes □ No
I swear that the information I have provided above is true and correct
____________________________________________________________
Signature of Sponsor
___________________________
Today’s Date
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200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 10
LOCK HAVEN UNIVERSITY OF PENNSYLVANIA
ROOMMATE SELECTION FORM
Welcome to the Student Life/Housing Department at Lock Haven University of Pennsylvania (LHUP). We ask
that you complete this compatibility profile form in its entirety and return tp the Center for Global
Engagement with the rest of your visiting/exchange packet by the due date indicated on the Center for Global
Engagement website. The Student Life/Housing Office uses this information in the roommate/room
assignment process.
Please Print Clearly and Legibly in English
HOME INSTITUTION NAME:
_______________________________________________________________________________________
NAME: Family____________________ First _______________________middle initial (if none, use “X”) ____
GENDER: o Male o Female PHONE # (INCLUDE COUNTRY CODE):
____________________________________
PERMANENT ADDRESS (HOME COUNTRY): Address _________________________________________________
City ________________________________ State/Province _______________________ Postal
Code_________________
Country Name ______________________________________
Do you have any disabilities or special needs which could affect housing accommodations? o Yes o No
If yes, please specify: ________________________________________________________________________________
__________________________________________________________________________________________________
All LHUP residence hall rooms and common areas are designated as Non-Smoking. Students and guests may choose to smoke off
campus, while respecting others and Hall Council Guidelines. Even though every room will be non-smoking, there are still students who
cannot tolerate a roommate who smokes (even outside of the halls).
Please answer the following: I would be bothered by a roommate who smokes (Select One):
o
Yes
o
No
Please Note: Very Important
• All Hall, Floor and/or Roommate Preferences are honored whenever possible on a first-come, first-serve basis.
The earlier you turn in your application to the Center for Global Engagement, the more likely that Student
Life/Housing Office can accommodate your wishes. Not all requests can be honored.
• LHU allows students who are having unsolvable roommate problems to change rooms providing that there are open
spaces in which to move.
• LHU International Exchange Student Requirement: International exchange students admitted to LHUP must
live on-campus when they are enrolled at LHU.
HOUSING ASSIGNMENT INFORMATION WILL BE PROVIDED
DURING INTERNATIONAL STUDENT ORIENTATION.
HALL/FLOOR PREFERENCE (PLEASE SELECT ONE):
o All international students are housed in a traditional double (2 beds, 1 for each occupant) in Woolridge Hall.
Woolridge has a kitchen on the first floor and community based bathrooms. Woolridge is comprised of 10-15%
international students with the remaining being United States students. Woolridge is a co-ed (men and women)
residence hall, but only same sex/genders room together. For more information visit the website at
www.lockhaven.edu/housing/woolridge.html
ROOMMATE PREFERENCES: (Only mutual requests will be honored)
If you know of a United States student studying at LHU and would like this person to be your roommate:
_______________________________________________
Name (First and Last): _____________________________________ Address: _________________________________
**All roommate requests must be returned to the Center for Global Engagement no later than November 1 for spring semester
and no later than April 1 for fall semester. All hall, floor, and/or roommate preferences are honored whenever possible on a
first-come, first-served basis.
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 11
INTERNATIONAL STUDENT HEALTH HISTORY FORM
In order to enroll in classes at Lock Haven University, you must complete the Health History Form. This
provides doctors/nurses with information should you need medical treatment. Please complete all sections of
this form. You will need to have a physical check-up by a licensed doctor/nurse/physician. Please make sure
the doctor/nurse/physician fills out the appropriate page and signs it. Please send the completed Health
History Form to the Center for Global Engagement with your completed application.
Part 1: Personal information to be completed by the student. Please type this information.
Part 2: Personal health history to be completed by the student. Please type this information.
Part 3: Physical examination to be completed by a licensed doctor/nurse/physician and signed.
Part 4: Required immunizations/vaccines to be completed by student or doctor/nurse/physician.
Part 5: Required tuberculosis information to be completed by student or doctor/nurse/physician.
Consent/Authorization for Treatment: I certify that the information provided on this Medical Health Form
is true and complete to the best of my knowledge. I also realize that this information is confidential and for
use by the Heath Service staff. I give permission for to be evaluated, diagnosed, and treated by Lock Haven
University Health Services under the direction of a nurse. It should be understood that under certain
circumstances, or emergencies, I may be referred to an area hospital, diagnostic testing facility, or medical
specialist for evaluation, diagnosis, and/or treatment. I understand that any costs for these services are
assumed by me and/or my insurance carrier.
Student Signature:
Date:
Family Name: ______________________ First Name: _____________________ Date of Birth: (___/___/___)
M D Y
Part 1: Personal information completed by the student.
I am an (select one): ___Exchange Student ___Matriculating Full-Time Student
Semester of Study: FALL 20___ Spring 20___ OR ACADEMIC YEAR 20___ TO 20___
Surname:
First Name, Middle Initial:
Home Address:
City:
State/Country:
Postal Code:
Phone Number:
Date of Birth: (Month/Day/Year)
o Male o Female
Name of Emergency Contact:
Phone Number (include country code):
Relationship to Student:
Emergency Contact’s Email Address:
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 12
Family Name: ______________________ First Name: _____________________ Date of Birth: (___/___/___)
M D Y
Part 2: Personal health history completed by the student. Please complete all questions
Allergies:
Medications:
Have you ever had:
Yes
No
Have you ever had:
Yes
No
Have you ever had:
Yes
No
Hepatitis A,B or C
Asthma
Attention Deficit Disorder
HIV
Pneumonia
Bipolar Disorder
Mononucleosis
Sinusitis
Depression
Chicken Pox
Seasonal Allergies
Anxiety
Measles (Rubeola)
Shortness of Breath
Panic Attacks
Mumps
Unexplained Fainting
Suicide Attempts
German Measles
(Rubella)
Thyroid Disease
Learning Disability
Tuberculosis
Diabetes
Eating Disorder
Rheumatic/Scarlet Fever
Hypoglycemia
Psychiatric problems
Gallbladder Disease
Arthritis
Alcohol/Drug Dependency
Gastroesophageal Reflux
Disease (GERD)
Back Problems
Female
Liver Disease
Headaches
Ovarian Cysts
Polyps (Colon)
Seizure Disorder
Breast Disease
Heart Disease, Murmur, or
Infection
Cancer
Past Pregnancy
High/Low Blood Pressure
Tumor/Cyst
Irregular Periods
Chest Pain/Discomfort
Anemia
Excessive Cramping
Eye Disorders/Disease
Physical Disabilities
Male
Ear Disorders/Disease
Any Surgeries
Hernia
Dental Disorders
Broken Bones
Testicular Problems
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 13
Part 3: Physical examination to be completed by a licensed doctor/nurse/physician & signed.
Medical Evaluation
Normal
Abnormal Findings Explained
Initials
BP:____/____
T____P____R____
Height: Weight:
Head, Face, Neck, and Scalp
Eyes (acuity) and Ophthalmic
Exam
Ear, Nose, Throat, Sinuses,
Mouth
Lungs and Chest
Heart
Abdomen
Skin
Neurological
G-U
Menstrual History (if
applicable)
Musculoskeletal
Neck
Back/shoulder/arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes
REQUIRED FOR ATHLETES
Heart Murmur
Femoral Pulses to Exclude Aortic
Corarctation
Physical Stigmata
Brachial Artery BP Sitting
Position
Doctor/Physician Information (MUST BE COMPLETE)
Doctor/Physician Signature:
Date: (M/D/Y)
Print Name:
Address:
City/Providence:
State/Country:
Postal Code:
Phone Number:
MANDATORY FOR ATHLETES ONLY
Medically cleared for sports
Yes No
Doctor/Physician Signature:
Date: (M/D/Y)
Family Name: ______________________ First Name: _____________________ Date of Birth: (___/___/___)
M D Y
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 14
Part 4: Required immunizations/vaccines to be completed by the student or licensed doctor/nurse/physician.
M / D / Y
Tdap (Tetanus Diphtheria Pertussis) (1 shot within the last 10 years)
___/___/___
Meningitis (1 shot within the last 5 years)
___/___/___
MMR (Measles, Mumps, Rubella) (2 shots)
___/___/___
___/___/___
Varicella (Chicken Pox) (2 shots OR age at time of disease)
Age:
___/___/___
___/___/___
Hepatitis B (3 shots)
___/___/___
___/___/___
___/___/___
Polio (IPV) (4 shots)
___/___/___
___/___/___
___/___/___
___/___/___
M / D / Y M / D / Y M / D / Y M / D / Y!
"
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"
"
Part 5: Required tuberculosis information to be completed by student or licensed doctor/nurse/physician.
Please answer the following questions:
Have you ever had close contact with persons known or suspected to have active TB disease? Yes No
Were you born in one of the countries listed below that have a high incidence of active TB disease? Yes No
(If yes, CIRCLE country)
Afghanistan
Comoros
Iraq
Namibia
Somalia
Algeria
Congo
Japan
Nepal
South Africa
Angola
Cote d’Ivoire
Kazakhstan
Nicaragua
Sri Lanka
Argentina
Demo. Rep. of Korea
Kenya
Niger
Sudan
Armenia
Demo. Rep. of Congo
Kiribati
Nigeria
Suriname
Azerbaijan
Djibouti
Kuwait
Pakistan
Swaziland
Bahrain
Dominican Republic
Kyrgyzstan
Palau
Syrian Arab Republic
Bangladesh
Ecuador
Lao Demo. Rep.
Panama
Tajikistan
Belarus
El Salvador
Latvia
Papua New Guinea
Thailand
Belize
Equatorial Guinea
Lesotho
Paraguay
Former Yugoslav Rep. of
Macedonia
Benin
Eritrea
Liberia
Peru
Timor-Leste
Bhutan
Estonia
Libyan Arab Jamahiriya
Philippines
Togo
Bolivia
Ethiopia
Lithuania
Poland
Tunisia
Bosnia & Herzegovina
Fiji
Madagascar
Portugal
Turkey
Botswana
Gabon
Malawi
Qatar
Turkmenistan
Brazil
Gambia
Malaysia
Rep. of Korea
Tuvalu
Brunei Darussalam
Georgia
Maldives
Rep. of Moldova
Uganda
Bulgaria
Ghana
Mali
Romania
Ukraine
Burkina Faso
Guam
Marshall Islands
Russian Fed.
United Rep. of Tanzania
Burundi
Guatemala
Mauritania
Rwanda
Uruguay
Cambodia
Guinea
Mauritius
St. Vincent and the Grenadines
Uzbekistan
Cameron
Guinea-Bissau
Mexico
Sao Tome and Principe
Vanuatu
Cape Verde
Guyana
Micronesia
Senegal
Venezuela
Central African Rep.
Haiti
Mongolia
Seychelles
Vietnam
Chad
Honduras
Morocco
Sierra Leone
Yemen
China
India
Mozambique
Singapore
Zambia
Colombia
Indonesia
Myanmar
Solomon Islands
Zimbabwe
Family Name: _________________ First Name: _____________________ Date of Birth: (___/___/___)
M D Y
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 15
Part 5: Continued required tuberculosis information
Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2010. Countries with incidence rates of ≥
20 cases per 100,000 population. For future updates, refer to http://apps.who.int/ghodata
Have you had frequent or prolonged visits* to one or more of the countries listed above with a high prevalence of TB disease?
(If yes, CHECK the countries, above)
Yes No
Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, long-term care facilities,
and homeless shelters)? Yes No
Have you been a volunteer or health-care worker who served clients who are at increased risk for active TB disease?
Yes No
Have you ever been a member of any of the following groups that may have an increased incidence of latent
M. tuberculosis
infection or active TB disease – medically underserved, low-income, or abusing drugs or alcohol? Yes No
If the answer is YES to any of the above questions, Lock Haven University requires that you receive TB testing as soon as
possible but at least prior to the start of the subsequent semester).
If the answer to all of the above questions is NO, no further testing or further action is required.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
TUBERCULOSIS (TB) RISK ASSESSMENT (to be completed by nurse/physician/doctor
provider)
Clinicians should review and verify the information above. Persons answering YES to any of the questions in Part K are
candidates for either
Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA), unless a previous positive test has been
documented.
History of a positive TB skin test or IGRA blood test? (If yes, document below) Yes No
History of BCG vaccination? (If yes, consider IGRA if possible.) Yes No
1. TB Symptom Check
Does the student have signs or symptoms of active pulmonary tuberculosis disease? Yes No
If No, proceed to 2 or 3
If yes, check below:
____ Cough (especially if lasting for 3 weeks or longer) with or without sputum production
____ Coughing up blood (hemoptysis)
____ Chest pain
____ Loss of appetite
____ Unexplained weight loss
____ Night sweats
____ Fever
Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x-ray, and
sputum
evaluation as indicated.
2. Tuberculin Skin Test (TST)
(TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration, write “0”.
The TST interpretation should be based on mm of induration as well as risk factors.)**
Date Given: M____/D____/Y_____ Date Read: M____/D____/Y_____
Results: _____mm of induration Interpretation: ____positive
____negative
"
"
!
!
!
!
!
Family Name: _________________ First Name: _____________________ Date of Birth: (___/___/___)
M D Y
"
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 16
Please Note: Please keep a copy of this form, and any attachments, for your records
Family Name: ______________________ First Name: _____________________ Date of Birth: (___/___/___)
**Interpretation guidelines
>5 mm is positive:
• Recent close contacts of an individual with infectious TB
• Persons with fibrotic changes on a prior chest x-ray, consistent with past TB disease
• Organ transplant recipients and other immunosuppressed persons (including receiving equivalent of >15 mg/d of
prednisone for >1 month.)
• HIV-infected persons
>10 mm is positive:
• recent arrivals to the U.S. (<5 years) from high prevalence areas or who resided in one for a significant* amount of
time
• injection drug users
• mycobacteriology laboratory personnel
• residents, employees, or volunteers in high-risk congregate settings
• persons with medical conditions that increase the risk of progression to TB disease including silicosis, diabetes mellitus,
chronic renal
failure, certain types of cancer (leukemias and lymphomas, cancers of the head, neck, or lung), gastrectomy or
jejunoileal bypass
and weight loss of at least 10% below ideal body weight.
>15 mm is positive:
• persons with no known risk factors for TB who, except for certain testing programs required by law or regulation,
would otherwise not be tested.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
Management of Positive TST or IGRA
All students with a positive TST or IGRA with no signs of active disease on chest x-ray should receive a recommendation to be
treated for latent TB with appropriate medication. However, students in the following groups are at increased risk of progression
from LTBI to TB disease and should be prioritized to begin treatment as soon as possible.
• Infected with HIV
• Recently infected with
M. tuberculosis
(within the past 2 years)
• History of untreated or inadequately treated TB disease, including persons with fibrotic changes on chest radiograph
consistent with prior TB disease
• Receiving immunosuppressive therapy such as tumor necrosis factor-alpha (TNF) antagonists, systemic corticosteroids
equivalent to/greater than 15 mg of prednisone per day, or immunosuppressive drug therapy following organ
transplantation
• Diagnosed with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung
• Have had a gastrectomy or jejunoileal bypass
• Weigh less than 90% of their ideal body weight
• Cigarette smokers and persons who abuse drugs and/or alcohol
•Populations defined locally as having an increased incidence of disease due to
M. tuberculosis
, including medically underserved,
low-income populations
________Student agrees to receive treatment
________Student declines treatment at this time
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Center for Global Engagement - 17
INTERNATIONAL STUDENT EXCHANGE & VISITING ITEMS TO SUBMIT
COPY OF PASSPORT
Please attach a scanned copy of your passport photo page with biographical information (name, country, place
of birth, etc.). Please ensure the scanned copy is legible and can be read easily. This is due at the time of the
application as this form is needed to create immigration documents. Without the copy of the biological page in
the passport, immigration documents cannot be issued. Please make sure your passport will be valid during
your planned stay in the United States, otherwise you should get this document renewed prior to coming to
the United States.
COPY OF ENGLISH LANGUAGE PROFICIENCY
Please attach a scanned copy of your scores from an English Proficiency exam (see what is accepted below) or
letters stating you are proficient in the English language (countries where English not the first language). If
submitting a letter, this should come from a English as a Second Language (ESL) professor/tutor or from your
International Office. This will be necessary to be issued a visa at the embassy/consulate.
EXAM
MINIMUM SCORE REQUIREMENT
TOEFL
197 (computer-based), 70 (internet-based), 525 (paper-based)
IELTS
5.5
Pearson: PTE Academic
46
Cambridge English
(CPE)
First B2, Advanced C1, Proficiency C3 - Cambridge English score of 160 or higher
SAT
Combined total score of 980, with at least 500 on the Evidence-based Reading and Writing
section
ACT
Composite of 20 with individual English and reading scores at or above 20
GTEC
1125
Duolingo
50
TOEIC
700
FINAL INSTRUCTIONS:
Any questions regarding the application should be sent to
John Gradel, Assistant Director of the Center for Global Engagement.
Completed applications should e-mailed in one (1) PDF format to
John Gradel, Assistant Director of the Center for Global Engagement.
Please do not send multiple attachments, as they may get lost in transmission.
NOTICE OF ACCEPTANCE:
Upon receipt of your completed application, your application will be processed in a timely manner. Upon
acceptance, your schools International Office will receive your acceptance packet that will include an
acceptance letter, immigration document, pre-arrival form, and pre-arrival guide with instructions of when to
arrive, what to bring, and a check-list of items to do prior to arrival.
Contact Information:
John Gradel, Assistant Director of the Center for Global Engagement - E-mail: jgradel@glockhaven.edu
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CGE International Exchange Visiting Student Application Master (Lock Haven University)

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Completed 23 July 2020

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