Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Chemeketa OTEMAE EXCHANGE Program 2019
Student Application Packet
IMPORTANT DEADLINES
A
pplication due: November 25, 2019
Chemeketa Interviews December 4, 2019
Notification to selected students
Confirmation of acceptance due from students
Required Orientation Sessions
December 5, 2019
December 10, 2019
December 12, 2019
D
eparture for Japan March 23, 2020 (Tentative)
WHAT HAPPENS NEXT…
After all applications are received and reviewed, Interviews will be conducted by the International Programs office, then
finalists will be interviewed by the Otemae University team as well. Once a students has been selected, notifications will
be sent via email to each applicant’s Chemeketa email address. To accept the Exchange position in the program you must
respond to the email offer by the deadline listed above. Registration for spring term classes will occur during the
mandatory pre-departure training session conducted the term prior to departure.
QUALIFICATIONS & RESTRICTIONS
Admission to Chemeketa
EXCHANGE PROGRAMS at Chemeketa are open to all current students. If you are not a current Chemeketa student
you must apply for Admission to Chemeketa
and receive a K# before registering for classes in the academic program
related to the exchange.
Age Restriction
Exchange students must be 18 years of age and have completed high school or equivalent prior to departure. If you
are between 16 and 18 years old you are allowed to take classes at Chemeketa. You must complete the Underag
e
A
dmissions Application process before registering for classes that are offered &/or are required to be taken prior to
applying. Please contact High School Partnerships at 503.399.5293 to begin the Under Age Admissions Application
p
rocess.
GPA & Other Academic Restrictions
Students must have a minimum 3.00 GPA to be considered for any Chemeketa EXCHANGE program.
Subject matter prerequisites apply as follows: OTEMAE applicants must be currently taking or have successfully
completed Japanese classes at Chemeketa with a c or better.
Passport
A valid passport is required for this trip. If you do not currently have a passport, apply NOW and attach a copy of the
order receipt to this application. Passports take between 4-6 weeks to be issued.
Other Exchange Requirements & Information:
Students must be willing to return to the US the first week of August & take the final exam for JPN class. The final will
be
scheduled in mid-August Date: TBA at this time. Review session(s) will be provided week prior to final. Failure to
attend classes in Japan, or failure to return on time and taking review sessions and final exam at Chemeketa, will
result in failure of the Japanese courses from Chemeketa. Failure to take the final will be cause for failure in the
Japanese class(es) associated with the program.
Program costs associated with this exchange will be the responsibility of the student as follows: Airline flights, food,
and personal items. Additional travel/excursions not included by Otemae University will be optional for exchange
students. Costs associated will be the responsibility of the student &/or student sponsor.
Program sponsors will have access to your progress as a part of their sponsorship of this program.
Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Page 1
Students must be willing to participate in program evaluation and promotion for Chemeketa prior to and after the
program. (Please attach your promotion proposal project outline to the application. Proposals will be finalized after
program selection.)
Must be able to travel to Japan, be full time students, and participate in Otemae leadership requirements. They must
also stay in Japan for the duration of the Otemae semester offered. Must be willing to follow all the rules and
regulations of the Otemae system. Failure to do so may result in immediate dismissal and required return to the US
at the student's expense.
Students must follow all the rules and regulations of the Chemeketa system while participating in this
exchange. Failure to do so may result in immediate dismissal and required return to the US at the student's expense.
Students must be willing to serve as ambassadors of Chemeketa representing the highest quality leadership skills. It is
a privilege to be selected for an exchange and is more than a regular study abroad program. Expectations and
opportunities of this program will be outlined in detail for the students selected. Student Leadership credits will be
earned for successful participants in the program.
APPLICATION MATERIALS
Your application packet will not be reviewed until we receive all of the following materials:
Study Abroad Exchange Program Student Application Page 2
Personal Essay Page 3
Exchange Agreement Terms and Conditions Page 4
International / Out-of-State Liability Waiver Page 5
Medical History / Emergency Contact Information Page 6
Accommodation Request Information Page 7
Release and Participant Conduct Agreement Page 8
Copy of Passport
Attach a copy of your passport. If you do not have a passport, apply and attach a copy of the order receipt.
Reference Letter
Application must include a written reference letter from one of the references listed on your application.
Unofficial Transcripts
Please include a copy of your unofficial transcript.
Current registration
Please include a copy of your current term schedule.
Mail, fax or email your signed application by the due date to:
Chemeketa Community College International Programs
4000 Lancaster Dr. NE, P.O. Box 14007
Salem, Oregon 97309
Fax: 503.365.4768
Email: international@chemeketa.edu
Chemeketa Community College is an equal opportunity/affirmative action employer and educational institution. To
request this publication in an alternative format, please call 503.399.5192. For a disability related accommodation, please
contact Disability Services at least two weeks prior to this event at 503.399.5192 (TTY/voice) or disability@chemeketa.edu
Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Page 2
Application Chemeketa Otemae Exchange 2019
Family Name: ___________________________ First Name: _______________________ Middle Initial: _____
Please fill out the information as it appears on your driver’s license of passport.
Preferred Name: _______________________ K#: ____________________ Date of Birth: _________________
If you are currently 17 but will be turning 18 prior to the time of departure for the overseas portion of this program you
must also have completed or are willing to complete the Under Age Admissions Application process
before applying to this
Exchange program.
Address: _____________________________ City: _____________________ State/Zip: _______ / __________
Home/Mobile Phone: __________________________ Chemeketa Email: ______________________________
Current School Information (high school or college, whichever applies)
School Name: __________________________________________________Current School GPA: __________
Expected Graduation Year: ______________ Minimum 2.75 GPA
Do you have a valid passport? No Yes
If so, please attach a copy. If not apply NOW and attach a copy of the receipt
Have you applied for financial aid? No Yes If yes, when? _________________________________
Are you receiving any tuition assistance? No Yes
If yes, what? Financial Aid Scholarship Tuition Waiver Other: _________________________
Do you speak any language(s) other than English? No Yes If yes, please list what language and
proficiency (beginner, intermediate, advanced): __________________________________________________
Which Japanese classes you have completed at Chemeketa?
JPN101 JPN102 JPN103 JPN201 JPN202 JPN203
References
List two people familiar with your character. Submit a reference letter from one of your references.
Name: _____________________________________________ Title: __________________________________
Phone: _________________________ Email: _____________________________________________________
Name: _____________________________________________ Title: __________________________________
Phone: _________________________ Email: _____________________________________________________
Agreement and Signature
May we release your name and Chemeketa email address to other students selected for the program?
No Yes
By submitting this application, I affirm that the facts set forth in it are true and complete. I authorize full investigation
of those
statements. I understand that if I am accepted as a Study Abroad participant, any false statements,
omissions, or other
misrepresentations made by me on this application may result in my immediate dismissal from
the program.
Printed Name: __________________________________
Signature: _____________________________________________ Date: __________________
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Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Page 3
Personal Essay
Name: _____________________________________Program Applying For: ____________________________
Limit each answer to no more than 100 words. Attach typed responses on separate sheets of paper.
1. Tell us why you are interested in participating in this exchange program. What do you hope to gain from
this experience if selected?
2. The Otemae Exchange program is designed to expand and challenge student world views. How do you
see yourself adapting to drastically different learning environment(s)?
3. Please describe your international travel and/or study experience.
4. What are you education/career goals?
5. Indicate any skills or qualifications you have which might be useful on this trip. Please include the
following:
a. your leadership experience
b. volunteer or work experience in an office setting
c. tutoring or other experience that would be relevant to this position
6. Exchange students are required to do service hours during the cycle of the program. This includes pre-
departure and/or post return promotion &/or exchange student support projects. Please list your ideas
for promoting or supporting future exchange students. Actual leadership proposals will be finalized after
program selection.)
7. Do you have any other questions or concerns you wish to address at orientation?
Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Page 4
Exchange Agreement Terms and Conditions
Name: _____________________________________ Applying For: OTEMAE Exchange 2019
If selected as a Chemeketa representative for the Otemae exchange 2019, I do agree to the following
requirements:
I have HS completion and am a current CCC student. I am a full time, degree seeking student or have a
Chemeketa degree at the time of application
I have a minimum 3.00 GPA
I am or will be 18 years of age or older at the time of my departure for the program
I am currently taking Japanese courses at Chemeketa or have successfully passed them with a c or better.
I am willing to return to the US the July 31st & take the final exam for Japanese class(es) in the program. I
will attend the review session(s) that will be provided week prior to final. I understand that, failure to
Failure to attend classes in Japan, or failure to return on time and taking review sessions and final exam at
Chemeketa, will result in failure of the Japanese courses from Chemeketa. Failure to take the final will be
cause for failure in the Japanese class(es) associated with the program.
I understand that program costs associated with this exchange will be the responsibility of the student as
follows: Airline flights, food, and personal items. Additional travel/excursions not included by Otemae
University will be optional for exchange students. Costs associated will be my responsibility &/or the
responsibility of my sponsor.
I understand that my program sponsors will have access to your progress as a part of their sponsorship of
this program.
I am willing to participate in program evaluation and promotion for Chemeketa prior to and after the
program.
Must be able to travel to Japan, be full time students, and participate in Otemae leadership
requirements. They must also stay in Japan for the duration of the Otemae semester offered. Must be
willing to follow all the rules and regulations of the Otemae system. Failure to do so may result in
immediate dismissal and required return to the US at the student's expense.
I agree to follow all the rules and regulations of the Chemeketa system while participating in this
exchange. Failure to do so may result in immediate dismissal and required return to the US at my expense.
I am willing to serve as ambassadors of Chemeketa representing the highest quality leadership skills. I
understand that it is a privilege to be selected for an exchange and is more than a regular study abroad
program. Expectations and opportunities of this program will be outlined in detail for me if selected.
Student Leadership credits will be earned for my successful participation in the program.
I understand that, If I do not adhere to the program requirements, I can be subject to either Otemae &/ or
Chemeketa disciplinary actions. I will also forfeit my exchange scholarship and be subject to owing Otemae
and/or Chemeketa for expenses involved in the exchange.
I authorize full investigation of all statements contained in this application and understand that any
misrepresentation or omission of facts called for will be sufficient cause for dismissal.
_________________________________________ __________________________
Applicant signature Date
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Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Page 5
International / Out-of-State Liability Waiver
Individuals who wish to participate in Chemeketa Community College International / out-of-state travel
programs must read and sign this statement which acknowledges their understanding of the liability issues
surrounding travel.
Participant agrees to indemnify and release Chemeketa Community College, Board of Education, officers,
its employees, and volunteers against any loss or expense including attorney fees resulting from bodily
injury, property damage, or personal injury arising out of any and all activities involved in travel. This hold
harmless and indemnification does not apply to gross negligence on the part of Chemeketa Community
College, Board of Education, officers, its employees, and volunteers.
Each participant will agree to purchase and/or maintain medical insurance covering accidental injury,
medical evacuation, dismemberment and/or death. Insurance should be provided on a worldwide basis.
It is understood that Chemeketa community College is not responsible for lost or stolen personal property,
airline delays, expenses, transfers, or hotel accommodations resulting in such delays.
Participation in this event is subject to the policies and procedures approved by the Chemeketa
Community College Board of Education.
Chemeketa cannot guarantee safety or eliminate all risks; monitor the choices of all individuals;
prevent all illegal acts; assure that American justice standards will be followed overseas;
assume responsibility for acts and actions outside program control.
Participant Information
Name: (please print) __________________________________________________________________________
Program: ____________________________ Sponsoring Department: _________________________________
Instructor/Trip Leaders: ______________________________________________________________________
Destination: ______________________ Date of Departure: ____________ Date of Return: _______________
Participant Signature: ________________________________________________ Date: __________________
Team leader: return completed form to the Risk Management Office, 2/215
Chemeketa Community College is an equal opportunity/affirmative action employer and educational institution. To
request this publication in an alternative format, please call 503.399.5192. For a disability related accommodation, please
contact Disability Services at least two weeks prior to this event at 503.399.5192 (TTY/voice) or disability@chemeketa.edu
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Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Page 6
Medical History / Emergency Contact Information
I understand that this information is voluntarily given and is correct to the best of my knowledge. I also
understand that it will only be used for first aid/medical procedures deemed necessary to protect my health.
Full Name: ________________________________________________________________________________
Address: _____________________________ City: _____________________ State/Zip: _______ / __________
Phone Day: _____________________ Evening: _____________________ Mobile: _______________________
Date of Birth: _________________ Blood Type: _________ Height: _______ Weight: _______ Sex: M F
Primary Physician: ______________________________________________ Phone: _____________________
Insurance Company: __________________________ Plan: _________________ Policy Number: ___________
Emergency Contact Information please list who should be contacted in case of an emergency
Primary Contact Name: _______________________________________ Relationship: ___________________
Address: _____________________________ City: _____________________ State/Zip: _______ / __________
Home Phone: ___________________ Mobile: __________________ Work Phone: ______________________
Email: _____________________________________________________________________________________
Secondary Contact Name: _____________________________________ Relationship: ___________________
Address: _____________________________ City: _____________________ State/Zip: _______ / __________
Home Phone: ___________________ Mobile: __________________ Work Phone: ______________________
Email: _____________________________________________________________________________________
Health Information
Allergies (medications, foods, other substances):
Dietary restrictions or requirements:
Current medications, vitamins or other supplements:
Other physical considerations and/or medical illnesses:
Chemeketa Community College is an equal opportunity/affirmative action employer and educational institution. To
request this publication in an alternative format, please call 503.399.5192. For a disability related accommodation, please
contact Disability Services at least two weeks prior to this event at 503.399.5192 (TTY/voice) or disability@chemeketa.edu
Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Page 7
Accommodation Request Information
Name: _________________________________________________ K#: ________________________
Address: ____________________________ City: ________________ State/Zip: _____ / __________
Phone Number: ___________________ Chemeketa Email: __________________________________
Chemeketa Community College is committed to providing access to all college sponsored programs and events
and does so in accordance with the Rehabilitation Act of 1973 and the Americans with Disabilities Act as
Amended (ADAAA) of 2008. To meet the requirements and guidelines as outlined in these acts, Chemeketa
provides a Disability Services office to determine reasonable and appropriate accommodations for students
with documented disabilities.
If you would like to request an accommodation(s) please go to:
https://denali.accessiblelearning.com/Chemeketa/ApplicationStudent.aspx
Please include the name, location, and dates of the overseas trip. You will be contacted by Disability Services
to schedule an appointment. Documentation of disability must be presented at the time of your appointment.
Requests for accommodations may take several weeks to review and implement and you are advised to make
the request early in your planning process.
If you need assistance in completing the application form contact Disability Services at 503.399.5192 or visit
the Salem campus Building 2 room 174.
I have read and understand how to request an accommodation.
Printed Name: _________________________________________
Signature: ___________________________________________ Date: __________________
Chemeketa Community College is an equal opportunity/affirmative action employer and educational institution. To
request this publication in an alternative format, please call 503.399.5192. For a disability related accommodation, please
contact Disability Services at least two weeks prior to this event at 503.399.5192 (TTY/voice) or disability@chemeketa.edu
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signature
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Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Page 8
Release and Participant Conduct Agreement
Please read and initial by each of the following statements. If you do not initial by each statement you will not
be considered for the program. Your initials indicate that you acknowledge, clearly understand and agree to
abide by the rules and guidelines set by Chemeketa Community College, the Office of International Programs
and the Trip Leader. Chemeketa policies, procedures and guidelines have been established to ensure a secure
and respectful academic experience abroad. Failure to follow Chemeketa’s policies, procedures and guidelines
stated on this form, in the application or published by Chemeketa or your Trip Leader can result in immediate
dismissal from the program at your own expense and without refund.
__________ STANDARDS OF CONDUCT
I understand that each country has its own laws and standards of acceptable conduct, including dress,
manners, morals, politics, drug use and behavior. I recognize that behavior violating those laws or standards
could harm Chemeketa’s relations with those countries and the institutions therein, as well as my own health
and safety. I will become informed of, and will abide by all such laws and standards of each country to or
through which I will travel during the program. I will comply with all rules and regulations issued by
Chemeketa, course instructors or any coordinating institution. It is within the course instructor’s discretion to
determine that my violation of such rules and regulations warrants my termination from the program. In the
event, I may be sent home at my own expense. I agree that Chemeketa has the right to enforce its rules and
regulations, including its student conduct, in its sole judgment, and that it will impose sanctions, up to
including expulsion from the program, for violating these rules and regulations or for any behavior detrimental
to or incompatible with the interests, harmony and welfare of Chemeketa, the program or other participants. I
recognize that due to circumstances of Study Abroad, procedures for notice, hearing and appeal applicable to
the student disciplinary proceedings at Chemeketa do not apply.
However, I will receive a notice of my violation and an opportunity to provide an explanation to an appropriate
official. If I am expelled, I consent to being sent home at my own expense with no refund of fees. I also agree
that:
1. I will not buy, sell or use drugs at any time;
2. I will not engage in abusive use of alcohol;
3. I will participate in all classes and scheduled activities unless ill; and
4. I will abide by dress and cultural codes suitable in the countries visited.
__________ ENGAGEMENT
While abroad, I am expected to be fully engaged in all class meetings and activities. I must engage in class
discussions and projects organized by my Trip Leader and other representatives. Visiting internet cafes to
research items will not substitute for taking an active role in class. I must keep my Trip Leader informed of any
plans of all independent travel outside of the itinerary.
__________ INDEPENDENT ACTIVITY
When participating in Chemeketa sponsored program, I understand that Chemeketa, course instructors or
travel coordinators have oversight for me even when I am not participating in supervised group activities. I
understand I may have the opportunity to leave the group periodically, subject to the course instructor’s
requirements for participating in and attendance at classes and other activities, which are a required part of
the overall program. During all times that I deviate from the program itinerary or group activities, I will be
responsible for my own safety and agree not to hold Chemeketa Community College liable for any injuries to
my person, including death, or property or any other losses resulting from independent travel on my part
before, during or after the program.
Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Page 9
__________ TRAVEL DOCUMENTS (PASSPORTS)
I understand I MUST have a passport to participate in a study abroad program and that for certain programs a
visa may be required in order to participate. I understand that if I do not provide my passport to the Office of
International Programs at the time in which it is requested, I may not participate in the program and will not
receive a refund of any program payments made.
__________ EMAIL ADDRESS
I understand that all communications regarding the study abroad program will be sent to my Chemeketa email
address.
__________ PERSONAL PROPERTY
I am solely responsible for my personal belongings and cannot hold other participants or Trip Leaders
responsible for damage to or loss of my property.
__________ PROGRAM CHARGES
I am responsible for any and all required payments and charges applicable to the program. I understand the
program’s cancellation policies and fees and agree to abide by them.
__________ PROGRAM CHANGES
Chemeketa may, in its sole discretion, determine that circumstances within a country may require the
cancellation of the program within that country. Chemeketa will provide me with as much advance notice as
possible of its intention to cancel the program in which I will participate. I also understand that Chemeketa, the
on-site coordinators or foreign government may prematurely terminate the program. I understand that
Chemeketa’s fees and program charges are based on current airfares, lodging rates and travel costs, which are
subject to change. If I leave or am expelled from the program for any reason, there will be no refund of fees
already paid. I accept all responsibility for loss or additional expense due to delays or other changes in the
means of transportation, services, sicknesses, weather, strikes, or unforeseen causes. If I become sick or
injured I will, at my own expense, obtain medical care and medical evacuation, if required.
__________ HEALTH AND SAFETY
There are no health-related reasons or problems, which preclude or restrict my participation in this program,
with or without accommodations. I am aware of all applicable personal medical needs. I have arranged,
through insurance or otherwise, to meet any and all needs of payment of medical costs while I participate in
the program. I recognize that Chemeketa is not obligated to attend any of my medical or medication needs,
and I assume all risk and responsibility therefore. If I require medical treatment or hospital care in a foreign
country or in the United States during the program, Chemeketa is not responsible for the cost or quality of
such treatment or care or medical evacuation from any location.
__________ RISKS OF EDUCATION ABROAD
I understand that participation in the program could involve risks not found in study at the college. These risks
include: traveling to and within, and returning from, one or more Study Abroad countries, political, legal, social
and economic conditions; different standards of design, safety and maintenance of buildings, public places and
conveyances; different standards of living, and limitations on the availability of police protection. I accept the
risk associated with airline changes, flight cancellations and agree to carefully review the policies and
guidelines published by my transportation providers.
Study Abroad Otemae Exchange
International Programs Chemeketa Community College
4000 Lancaster Dr. NE, P.O. Box 14007, Salem, Oregon 97309
Page 10
__________ TRAVEL ARRANGEMENTS
I understand the Office of International Programs arranges group travel arrangements. If I choose to deviate
from my return flight schedule: I will be responsible for all arrangements and will be required to pay any
change fees directly to the airline and/or service provider. I will not leave my program prior to the published
end date. I will keep my Trip Leader informed of any intended flight deviations. If I leave the program prior to
its completion for any reason, I understand the University has no responsibility to provide or arrange
transportation.
__________ PERMISSION FOR REPRODUCTION
I hereby grant to Chemeketa Community College (hereinafter Chemeketa), its legal representatives and
assigns, the right and permission to copyright, use, reuse, broadcast, publish, store, manipulate, and retrieve
any video, audio, photographic, or electronic reproductions of me, in conjunction with only my first name.
Additionally, I understand that my image, along with my identity, is used by Chemeketa in any advertising
campaign, or other use, may result in unwanted attention by third parties or notoriety. I furthermore waive my
right to inspect or approve the finished reproduction or to lay claim to any benefits derived therefrom. I certify
that I am of legal age to enter into a contractual agreement and that I have read and understand the foregoing
before affixing my signature below.
Printed Name: _______________________________________________ K#: __________________________
Signature: __________________________________________________ Date: _________________________
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