Fill - Free fillable Domestic Exchange Application (Pitzer College) PDF form

Pitzer College Office of Study Abroad and International Programs

West Hall, Suite Q100, 1050 North Mills Avenue, Claremont, CA 91711

Telephone 909.621.8104  Email exchanges@pitzer.edu

Pitzer College Domestic Exchange Application

Semester(s) and year(s) to study at Pitzer College Fall of ______________ Spring of ______________

Name (as shown in passport) _______________________________________________________________

_______________________ ___________________ _________________________________ ____________________

Name you prefer to be called Birth Date (month/day/year) Country of Birth Gender Prounouns

__________________________ ______________________________ __________________ _____________________

Passport Number Country of Citizenship Expiration Date (mm/dd/yy) Place of Issue

Home University ___________________________________________________ Class standing 1

year

Major ______________________________________________ Faculty Adviser ___________________________________

Student’s Contact Information at University

____________________________________________________________________________________

Street Address and/or Box Number City State or Province Postal Code Country

_________________________ _________________________ _____________________________________________

Mobile Phone University Email

Permanent Contact Information An address not listed above where you can always be contacted or receive mail

____________________________________________________________________________________

Street Address and/or Box Number City State or Province Postal Code Country

_________________________ _____________________________________________

Phone Personal Email

_____________________________________________ In the event of an emergency, should this person be contacted? Yes No

Mother/Guardian

____________________________________________________________________________________________________

Street Address and/or Box Number City State or Province Postal Code Country

_________________________ _________________________ _____________________________________________

Mobile Home Phone Email

_____________________________________________ In the event of an emergency, should this person be contacted? Yes No

Father/Guardian

____________________________________________________________________________________________________

Street Address and/or Box Number City State or Province Postal Code Country

_________________________ _________________________ _____________________________________________

Mobile Home Phone Email

_________________________________________________________ _________________________________________

Name of Emergency Contact - only if you selected ‘no’ for all people listed above Relationship to you

_________________________ _________________________ _____________________________________________

Mobile Home Phone Email

Pitzer College Office of Study Abroad and International Programs

West Hall, Suite Q100, 1050 North Mills Avenue, Claremont, CA 91711

Telephone 909.621.8104  Email exchanges@pitzer.edu

Pitzer College Domestic Exchange Application

Name _______________________________________________________________

Courses in Progress at your Home Institution - list courses in which you are currently enrolled

_____________________________________________________________ _____________________________________________________________

Dept. or Field Course Title Dept. or Field Course Title

_____________________________________________________________ _____________________________________________________________

Dept. or Field Course Title Dept. or Field Course Title

_____________________________________________________________ _____________________________________________________________

Dept. or Field Course Title Dept. or Field Course Title

Language Skills

List any languages in which you consider yourself a native speaker ____________________________________________

List any languages you studied in high school and the number of years you studied them

____________________________________________________________________________________________________

List all languages completed for college credit

Language ____________________________ courses completed (indicate level, course number, semester, and year)

____________________________________________________________________________________________________

Language ____________________________ courses completed (indicate level, course number, semester, and year)

____________________________________________________________________________________________________

Language coursework currently in progress

____________________________________________________________________________________________________

What other language courses will you take prior to participation in this program (including summer courses)?

____________________________________________________________________________________________________

Pitzer College Office of Study Abroad and International Programs

West Hall, Suite Q100, 1050 North Mills Avenue, Claremont, CA 91711

Telephone 909.621.8104  Email exchanges@pitzer.edu

Pitzer College Domestic Exchange Application

Information Distribution Waiver

Please enter yes or no for each statement. If not indicated, permission to release this information will be assumed.

 Pitzer College may distribute my email address and phone number to other program participants before the

program. Yes No

 Pitzer College may release information related to my participation on this program to my parent(s) or guardian(s).

Yes No

 After completing the program, Pitzer College may distribute my email address or phone number to prospective

students who wish to speak to program returnees for additional program details. Yes No

 Pitzer College may use my written materials from the field book, the directed independent study project (DISP) and

the program evaluation for educational development purposes. Yes No

Signature __________________________________________________________________ Date ____________________

Student Consent

I hereby make application to study abroad, and I do so with the understanding that should I accept an offer of

admission; I will agree to accept and abide by the regulations of the sponsoring institution(s). I understand that

photographs may be taken during program participation and may be used in future publications. I agree to participate

fully in the orientation, all program components and evaluation process, and will observe deadlines for submission of

all required materials. Pitzer College may release information related to my participation on this program to officials

from my home institution (e.g. financial aid officers, study abroad staff, faculty advisers, Student Affairs Office, etc.).

 I give Pitzer College permission to release information related to my participation on this program to officials from

my home institution (e.g. financial aid officers, study abroad staff, faculty advisers, Student Affairs Office, etc.).

 I further give permission to my university to release my transcripts and information applicable to my suitability for

International Exchanges to Pitzer College.

 I understand that I am required to request that an official transcript be sent from the registrar of my home

university to Pitzer College.

Name _______________________________________________________________

Signature __________________________________________________________________ Date ____________________

Pitzer College, Office of Study Abroad, West Hall, Suite Q100, 1050 North Mills Avenue, Claremont, CA 91711

Telephone 909.621.8104  Email studyabroad@pitzer.edu

Pitzer College Health Report - Student Section

Student Name _______________________________________________________________

Home University ___________________________________________________ Semester of Participation ________________

Birth Date ___________________ How would you describe your general health?  Excellent  Good  Fair  Poor

(month/day/year)

Do you have any food allergies or dietary restrictions based on medical conditions or religious beliefs? (Be specific) _________

___________________________________________________________________________________________________________

Do you have any known allergies to medications or vaccines? (Provide details) ________________________________________

___________________________________________________________________________________________________________

Please check if you have had:

 Amoebic dysentery

 Anemia

 Appendicitis

 Asthma

 Back Problems

 Bleeding/clotting problems

 Bronchitis

 Bone infection

 Cancer/leukemia

 Chicken pox

 Chronic cough

 Chronic diarrhea

 Chronic rash

 Depression

 Diabetes

 Diphtheria

 Ear infection

 Eating disorder (anorexia/bulimia)

 Epilepsy

 Eye trouble

 Fainting spells

 Hay fever

 Hearing loss

 Heart trouble

 Hepatitis

 Hernia problems

 Immune system problems

 Kidney trouble

 Malaria

 Measles

 Menstrual difficulty

 Migraine headache

 Mononucleosis

 Mumps

 Painful/swollen joints

 Pneumonia

 Poliomyelitis

 Recent weight loss or gain

 Recurrent dizziness

 Rheumatic fever

 Rubella

 Scarlet fever

 Severe headaches

 Sinus problems

 Smallpox

 Stomach ulcer

 Tetanus

 Tonsillitis

 Tuberculosis

 Typhoid fever

 Unexplained fevers

 Whooping cough

Explain any recent or serious episodes (Be specific) _______________________________________________________________

___________________________________________________________________________________________________________

Have you had any serious illnesses not covered above? If yes, please describe ________________________________________

___________________________________________________________________________________________________________

In the last five years, have you consulted, or been treated by a psychiatrist, clinical psychologist, drug/alcohol counselor, or

other mental health professional? If yes, please explain here _______________________________________________________

___________________________________________________________________________________________________________

Recent intradermal tuberculin test date (optional, but recommended) _____________ Results _____________

If positive, date of last chest x-ray _____________ Results _____________

Can you participate in the essential functions of this program without accommodation?  Yes  No If no, what type of

accommodation is required? __________________________________________________________________________________

___________________________________________________________________________________________________________

I hereby verify that all of the information contained in this form is accurate and acknowledge that failure to provide accurate

information may result in my dismissal from the program. I agree to notify Pitzer College of any significant changes in my

health that occur after submitting this form. I understand the Office of Study Abroad may share this health report with my study

abroad program provider or host institution.

Student’s signature _________________________________________________________ Date_____________________

(month/day/year)

PITZER COLLEGE EXTERNAL STUDIES APPLICATION PART E: HEALTH REPORT – STUDENT SECTION I

1050 N. MILLS AVENUE PHONE: (909) 621-8104 OR FAX (909) 621-0518

CLAREMONT, CA 91711

EMAIL: EXTERNAL_STUDIES@PITZER.EDU

PITZER COLLEGE EXTERNAL STUDIES APPLICATION PART E: HEALTH REPORT – STUDENT SECTION I

1050 N. MILLS AVENUE PHONE: (909) 621-8104 OR FAX (909) 621-0518

CLAREMONT, CA 91711

EMAIL: EXTERNAL_STUDIES@PITZER.EDU

PITZER COLLEGE EXTERNAL STUDIES APPLICATION PART E: HEALTH REPORT – STUDENT SECTION I

1050 N. MILLS AVENUE PHONE: (909) 621-8104 OR FAX (909) 621-0518

CLAREMONT, CA 91711

EMAIL: EXTERNAL_STUDIES@PITZER.EDU

A study abroad program may create emotional and physical stress for those living in a different environment for an extended

period of time. You are asked to carefully consider your physical and mental health in relation to the exchange program’s location,

requirements, and the conditions in which you will be living.

This form is required after acceptance to an exchange program, but may be submitted with the initial application. Additional

sheets may be submitted if needed to provide further details.

Pitzer College, Office of Study Abroad, West Hall, Suite 100, 1050 North Mills Avenue, Claremont, CA 91711

Telephone 909.621.8104  Email studyabroad@pitzer.edu

Pitzer College Study Abroad Request for Accommodation

This form must be completed by all participants and is due by the deadline indicated in their acceptance letter.

Pitzer College does not discriminate on the basis of disability in the administration of its admission policies, educational

policies, or other College-administered programs. In many of the countries in which we approve or operate study abroad

programs, however, possibilities for reasonably accommodating students with certain physical, medical, psychological

or learning disabilities may be limited. The ability of Pitzer College, the exchange host institution or the program sponsor

to offer reasonable accommodations during an exchange will vary from program to program and is addressed on a case

by case basis.

If you have a physical, medical, psychological, or learning disability, or there are any other factors for which you may

require reasonable accommodation or the ongoing care of a physician or therapist, it is essential that you clearly state

this information on the form below. We will discuss your case with you, request additional documentation or information

if necessary, and make an assessment of what reasonable accommodations or arrangement for ongoing care can be

made to meet your needs while on exchange. You can then make an informed decision about the viability of your

participation on a specific program. The information provided by students on this form will be maintained separately

from applications to participate in an exchange program and will not be considered in admissions decisions for the

programs. Please check one of the boxes below:

□ I do not have any physical, medical, psychological condition, learning disability or any other situation for which I will

require reasonable accommodation in my program or ongoing care of a physician or therapist. Should this change

prior to participation, I understand I must notify the Office of Study Abroad and International Programs immediately

to determine what reasonable accommodations can be provided. Skip questions 1, 2 and 3 and complete the

information at the bottom of this page.

□ I have a physical, medical, psychological condition, learning disability or other situation for which I will or may

require reasonable accommodations or the ongoing care of a physician or therapist while participating on my

exchange program. If you check this box, please answer questions 1, 2 and 3 and complete the information at the

bottom of this page.

1. What accommodation are you requesting? Be specific. Please describe in detail the nature of your disability or

special need. Continue on the back of this form if you need more space to write.

2. How do you anticipate your disability or special needs will impact your participation on the program?

3. What accommodations are currently provided by your home institution to meet your special needs? (Please note

that Pitzer College may not be able to provide a similar level of reasonable accommodation while you are on

exchange.)

I give permission to the Office of Academic Support, the Dean of Students or other appropriate officials at my home

institution to release information about the disability, accommodations or special needs I have identified above to

Pitzer’s Office of Study Abroad and International Programs or the sponsor of my exchange program. I have read and

understood this form in its entirety and certify that the information I have provided is true.

Name ____________________________________________________________________________

Signature ______________________________________________ Date _______________________________________

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