Fillable Governors State University Study Abroad Application Packet

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Governors State University Study Abroad Application Packet

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1
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Study Abroad Application Packet
Application Procedures
Students must complete the following Governors State University (GSU) study abroad application requirements in order
to receive approval for study abroad. Students must also meet admission requirements set by their chosen study abroad
program and be accepted into the program. The Office of International Services (OIS) approval does not guarantee
admission into any study abroad program outside of GSU. Please check the GSU website for study abroad requirements.
Step I- Make a Study Abroad Advising Appointment with the Study Abroad Coordinator in the Office of International
Services to discuss your plans. To schedule an appointment, please email or call the Study Abroad Coordinator.
Step II - Submit the Following Documents to the Office of International Services:
• Completed Study Abroad Application
• Completed Study Abroad Course Approval Form (for students attending study abroad programs that offer credit outside
of Governors State University.)
Step III - Upon confirmation of study abroad participation from the Study Abroad Coordinator, students must submit the
following documents to the Office of International Services:
• Copy of front page of passport (which includes your picture, passport number, expiration date)
• Non-refundable deposit (amount depends on program – some programs require a deposit at the time of application)
Step IV - After completion of Steps I-III, students are eligible to apply for the GSU Study Abroad Scholarship. To be
considered for the scholarship, students must submit the following documents to the Office of International Services:
• Completed Study Abroad Scholarship Form
• 2 Academic or Professional Letters of Recommendation
• 500-1000 Word Statement of Purpose Essay with Follow-on Project
• Resume
Please return all items to the Office of International Services, GMT 168 with attention to Study Abroad Coordinator, GMT
151. Incomplete or late applications will not be considered for the scholarship. Check the GSU website or contact the
Study Abroad Coordinator for the Study Abroad Scholarship Application deadlines.
OIS recommends that you copy all of your documents for your records.
Passports MUST be valid at least 6 months BEYOND your arrival date back in the United States.
It is your responsibility to know if you need a visa to travel to another country. Please check with the Department of State’s
website if you are a US citizen or permanent resident for visa requirements. For nonimmigrants, please check with your
home country’s government to confirm whether or not you would need a visa. You should also reference the Department
of State’s website to ensure that you obtain all of the proper immunizations for the country to which you will travel.
2
Study Abroad Student Information
Name: ____________________________________ First Name: ____________________________________ M.I.: ___________
GSU ID: _________________________ Gender: _____________ Email: ______________________________________________
Address: __________________________________________________________________________________________________
Date of Birth (mm/dd/yyyy): _____________________________ Phone: ______________________________________________
Major(s): _____________________________ Minor(s): _____________________________ Cumulative GPA: _______________
Number of credits completed: Undergraduate ____________________________ Graduate _____________________________
Expected Graduation Date: ___________________________________________________________________________________
Program Destination: ___________________________________ Program Semester: ___________________________________
Program Title: ______________________________________________________________________________________________
Program Dates: ________________________________________ Course Number: ______________________________________
I plan to take the course for credit: Yes No, I plan to audit*
*Note: Auditing is an option for some programs, it is a way for students to participate who do not need course credit. Students pay $75 instead of tuition.
Do you have a passport? Yes No
Country of Citizenship: ______________________________________________________________________________________
Full Name as it appears on passport: __________________________________________________________________________
Passport Expiration Date: _______________________________ Passport No.: ________________________________________
Emergency Contact Information
The information requested below is sought to assist Governors State University officials and inform them of your emergency
contact information in the unlikely event of an emergency during your study abroad experience.
Name: __________________________________________________ Relationship: __________________________________
Address: __________________________________________________________________________________________________
Email: __________________________________________________ Phone: ________________________________________
Secondary Contact Name: _________________________________ Relationship: __________________________________
Address: __________________________________________________________________________________________________
Email: __________________________________________________ Phone: ________________________________________
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Study Abroad Application
3
In consideration of being allowed to participate in a Governors State University study abroad program, I hereby agree to the
following conditions of participation:
1. Personal Conduct: I understand that as a visiting student in a foreign country, I shall be subject to the laws of that country and the
rules and regulations of the institution with which I am engaged. I further understand and agree to the following conduct stipulations:
a. While enrolled in and attending the study abroad program (herein after referred to as Program), students are expected and required
to abide by the rules and regulations established by Governors State University. The actions that constitute misconduct for which
students may be subject to disciplinary penalties are promulgated in the Governors State University community standards handbook.
A current copy of which is available at: http://www.govst.edu/communitystandards/
b. Violations of the rules of student conduct as described above may result in the University instituting disciplinary or administrative
action proceedings. Regulations governing student conduct as well as disciplinary proceedings and appeals can also be found in the
student handbook.
c. The disciplinary process may result in dismissal of the charges, a verbal or written warning, program probation, or termination from
the program. Termination from the program will result in the loss of academic credit from the program. Students terminated from the
program will be held responsible for all program costs incurred on their behalf.
d. For the duration of the program students are considered to be engaged in an official University activity and must comply with all the
rules and regulations that pertain thereto.
2. Academic Responsibility: I understand that I am responsible for attendance at all classes and scheduled activities. I also understand
that the GSU student conduct code will apply to me while I am enrolled in this study abroad program and it is my responsibility to be
informed of the code and the resulting misconduct proceedings, should a violation occur. These regulations and procedures can be
found in the GSU student handbook: http://www.govst.edu/communitystandards/
3. Financial Liability: I agree to bear any additional costs if approximate rates quoted by the University increase due to currency
exchange rate fluctuations or inflation prior to my departure and during my residence abroad. I also understand that Governors State
University will bill me for any outstanding charges, damages, etc., incurred by me at the program site. My GSU academic transcript
will be encumbered and my study abroad credit will not be posted until these charges have been resolved.
4. Responsibility During Free Time: I understand that during free time within the period of the program and after the period of the
program I may elect to travel independently at my own expense. I agree to inform the proper authorities abroad of my travel plans
and understand that Governors State University and/or staff or its counterparts overseas are not responsible for me while I am traveling
independently during such free time.
5. Theft and Other Crimes: I agree to release Governors State University and its staff from any liability for damage to or loss of my
possessions, injury, or death arising out of crimes during the period of the program.
6. General Release and Waiver: I waive Governors State University and its staff from any liability for damage to or loss of property,
injury, illness, or death during the period of the program arising on the part of fellow participants, host family members, agencies and
educational organizations, persons or groups with which the University contracts for the provision of services for the program or which
have been suggested by program faculty as resources for the students.
7. Governors State University Student Responsibility: I understand that as a Governors State University study abroad student, I will be
viewed as a representative of my university and my country. It is my intention to act as a good will ambassador and conduct myself
in a fitting manner.
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Statement of Responsibility and Assumption of Risk
4
Refunds & Withdrawals Policy
Refunds
Any payments made to Governors State University for participation in study abroad programs will not be refunded under any circumstances.
Risks
Travel abroad involves some risks and uncertainties not present at Governors State University (GSU), including risks of injuries, damages
or other harm that may arise during the overseas study period. GSU students must accept these risks and uncertainties as well as accept
responsibility for their own safety. Governors State University cannot guarantee students’ safety while living abroad.
Voluntary Withdrawal
GSU students who choose to withdraw from a study abroad program must be aware that GSU will not assume any financial responsibility
for such a voluntary withdrawal. Furthermore, GSU students must pay careful attention to the cancellation/withdrawal policies of the host
university or program provider.
The Office of International Services will notify Financial Aid of your withdrawal. Please note that students who withdraw after a program
begins should expect to repay any financial aid, including scholarships and loans, awarded for the program.
Involuntary Withdrawal
Though very rare, GSU students may be required to withdraw from a study abroad program involuntarily. Reasons could be – but are not
limited to – medical needs, political instability, natural disasters or other evacuations. The Office of International Services will make
every reasonable effort to advocate for refunds of unspent expenses. However, Governors State University will not assume any financial
responsibility for such involuntary withdrawals.
It is expected that after a program is cancelled or after it is determined that a student must withdraw from a program involuntarily, the
student will depart from the program location within 24 hours. In some cases, a student may be asked to sign a document acknowledging
that her/his participation in the program has concluded.
The Office of International Services reserves the right to cancel any overseas program where the security of GSU students might be
threatened. This may occur even if the United States Department of State has not issued a travel warning or travel alert. Governors State
University will not assume any financial responsibility for a canceled study abroad program.
If a host university or program provider terminates the participation of a GSU student in a study abroad program, Governors State
University will not assume any financial responsibility for such an involuntary withdrawal.
The Office of International Services will notify Financial Aid of all involuntary program withdrawals. Please note that students who are
involuntarily withdrawn from a program after it begins should expect to repay any financial aid awarded for the program.
All of the information that I have entered above is correct to the best of my knowledge. Additionally, I have read, understand, and accept
each of the above listed conditions.
_______________________________________________________________________________________________________________________
Signature of Participant Date
For Office Use – Application Documents ____ Refunds & Withdrawal Policy
____ Application Form ____ Information Release Consent Form and Survey
____ Statement of Responsibility & Assumption of Risk ____ Course Approval Form (if applicable)
____ Health Questionnaire ____ Passport Copy
Received by: Date Received:
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Statement of Responsibility and Assumption of Risk
5
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Information Release Consent Form and Survey (Optional)
____ I consent to allow the Office of International Services to release information regarding my participation in the Study
Abroad Program. This may include my name, hometown, telephone number, major and Email address. This information can
be shared with the following parties (please check to which of the following parties you agree to release your information):
____ Anyone
____ Media (no phone or Email will be shared)
____ My parents, legal guardians, or family members
____ Faculty and/or staff (at Governors State University or your program abroad)
____ Students interested in participating in Study Abroad programs in the future
____ I do not consent to have my information released
_______________________________________________________________________________________________________________________
Student Name Student Signature Date
1. State briefly any additional information that may be useful in evaluating your candidacy, including any travel or
residence in other countries or regions of the United States.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2. Interests and/or hobbies: ________________________________________________________________________________
_______________________________________________________________________________________________________
3. Activities and/or organizations: ___________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4. Describe your plans for financing your participation in a study abroad program. __________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
The following questions are for data collection and will not affect the status of your application:
5. Are you receiving financial aid? Yes No
6. Are you a Federal Pell Grant Recipient? Yes No
7. Are you a First Generation College Student? Yes No
8. Will you be utilizing VA education benefits? Yes No
6
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Study Abroad Health Questionnaire
Name: _________________________________________________ Program: ____________________ Date: _______________________
An important component of your experience abroad is the state of your health. Because we want this experience to be positive and
because we also want to be of help to you in case of sickness or injury, we ask that you complete this questionnaire as completely and as
candidly as possible. Please keep in mind that your answers do not affect your status as a program participant. Also this information will
be held in strict confidence, to be shared with program staff only on a need-to-know basis.
1. Do you have a chronic health condition? _______ If so, please describe this condition.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
2. Do you take, regularly or sporadically, a medication or medications? _______
If so, please identify the medication(s) and your dosage schedule.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
3. Do you have a physical condition that could affect your participation in program events (or require special steps on our part to make
your participation possible)? _______ If so, please describe this condition.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
4. Do you suffer from an allergy or allergies? _______ If so, please elaborate.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
5. Have you any dietary restrictions? __________ If so, what are they?
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
6. Is there anything in your medical history — illness or injury — about which it would be potentially useful for us to know (to ensure
your full participation in the program)? ______ If so, please elaborate.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Student Signature
Thank you for completing this form. If you would like to elaborate on anything here or if you want to discuss a problem outside the
framework of these questions, please feel free to attach a separate sheet of paper. Also, you are welcome to speak privately (and
confidentially) with an Office of International Services staff member about any potential medical problem or concern you may have.
7
COURSE # AND TITLE CREDIT HOURS* REQUESTED GSU
EQUIVALENT
GSU EQUIVALENT/APPLIES TOWARD SIGNATURE OF ACADEMIC ADVISOR AND DEAN
As listed at host institution Verify credit
hours with OIS
(i.e., specific course,
major, minor, etc.) **
To be completed by Academic Advisor and Dean
*Number of credit hours awarded may be more or less depending on the transcript from the sponsoring institution or program.
** Approved courses will be determined by the academic advisor and dean.
(Students must provide course title and description, number of contact hours, and whether it is a lower or an upper division course.) Provided that the
student passes these courses with at least a “C” grade, the above approved courses will be accepted for the equivalency and credit indicated.
NOTE: Courses will be accepted subject to program approval by the Office of International Services. The student is responsible for confirming that his/her
program provides grades or an evaluation. Certificates of attendance or completion do NOT meet the requirements for transfer of credit.
Study Abroad Course Approval Form
________________________________________________________________________________________________________________________
Student Name GSU ID Number Name of Program School Issuing Transcript
________________________________________________________________________________________________________________________
City and Country of School Abroad College and Major/Minor Study Abroad Term Academic Advisor(s)
For acceptance of the above courses toward the degree, the official transcript of credit (under seal) must, as soon as possible, be sent
directly from the school at which the courses are taken to the Office of International Services:
via FedEx/UPS or US Postal Service:
Office of International Services – Attn: Amy Schoenberg
Governors State University
1 University Parkway, GMT168
University Park, IL 60484
Return this completed document to the Office of International Services. A copy will be provided to your academic advisor.
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Note: This form is only required for students who are attending study abroad programs that offer credit outside of GSU.
8
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Study Abroad Scholarship Application Instructions
Step I – The Student must meet all the eligibility criteria required for study abroad scholarship program and be accepted to
participate in a program.
Step II – Check the deadline for scholarship application submission on the GSU website, program information handout or
by contacting the Study Abroad Coordinator.
Step III – Complete and submit all of the following supporting documentation to the Office of International Services –
GMT168 with the attention to the Study Abroad Coordinator:
1. Study Abroad Scholarship Application Form
2. Statement of Purpose Essay with Follow-on Project
3. Two letters of recommendation or recommendation forms filled out by academic or professional references.
4. A current copy of your resume
Statement of Purpose Essay with Follow-on Project Specifics:
• 500-1000 words
• Typed, one-inch margins, double-spaced, 12 pt. font
• Include one-line header in the top-right corner with your Name and Student ID
• Pay attention to detail in terms of grammar and style
The essay is comprised of three parts. Please read below for details.
1. Reasons for Studying Abroad – Address the impact that your study abroad program will have on your academic,
professional, and personal goals. You should also address the impact that receiving the Study Abroad Scholarship
would have on your achievement of these goals.
2. Challenges – What challenges, if any, did you face in your decision to study or intern abroad? How did you meet these
challenges and what impact do you foresee them having on your experience abroad? These could include, but are not
limited to, being a parent, being a non-traditional student, having a learning or physical disability, being in a field of
study for which it is difficult to incorporate study abroad, etc.
3. Follow-on Project Proposal – The Follow-on Project Proposal is your chance to explain how you will give back by inspiring
others to pursue their own experiences abroad. To help expand the impact of the GSU Study Abroad Scholarship Program,
all scholarship recipients are required to carry out a Follow-on Project that helps to promote international education and
study abroad. This project can be done virtually while you are abroad, on your home campus or in your local community
and must be completed within six months of your return to the United States. All applicants must describe their project
proposal within the essay as part of and this proposal is closely reviewed during the selection process.
Step IV – Scholarships are awarded based on basic eligibility criteria, cumulative GPA, essay with follow-up project,
letters of recommendation and overall impression. Students who are awarded will be notified as to the decision on their
application within one month after the application deadline and provided additional information and details on the award.
*Note: students who have received a GSU Study Abroad Scholarship must wait one year prior to applying again.
9
Name: ____________________________________ First Name: ____________________________________ M.I.: ___________
GSU ID: _________________________ Gender: _____________ Email: ______________________________________________
Address: __________________________________________________________________________________________________
Date of Birth (mm/dd/yyyy): _____________________________ Phone: ______________________________________________
Major(s): _____________________________ Minor(s): _____________________________ Cumulative GPA: _______________
Number of credits completed: Undergraduate ____________________________ Graduate _____________________________
Expected Graduation Date: ___________________________________________________________________________________
Program Destination: ___________________________________ Program Semester: ___________________________________
Program Title: ______________________________________________________________________________________________
Program Dates: ________________________________________ Course Number: ______________________________________
I plan to take the course for credit: Yes No, I plan to audit*
*Note: Auditing is an option for some programs, it is a way for students to participate who do not need course credit. Students pay $75 instead of tuition.
Current Student Status
Undergraduate – (circle one) Freshman Sophomore Junior Senior
Graduate
Doctoral
Honors
Non-degree
Certificate
Previous scholarship awards received by GSU* ___________________________________________________________________
*Note: Students are allowed to receive no more than one Study Abroad Scholarship per academic year.
Application Checklist
Completed scholarship application
Statement of Purpose Essay with Follow-on Project
I understand it is my responsibility to make sure all of the application materials are submitted to the Office of International
Services by the deadline. If my application is incomplete, I understand that I may not be considered for an award.
___________________________________________________________________________________________________________
Student signature Date
Submit the Study Abroad Scholarship application and required documents to:
Attn: Study Abroad Scholarship Committee
Governors State University
1 University Parkway, GMT 168
University Park, IL 60484
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Study Abroad Scholarship Application
Two letters of recommendation
A current copy of your resume
10
Instructions for Student: Complete information below, print and sign two forms and give to an academic or professional
reference. At least one reference must be from a GSU faculty member or academic advisor. We WILL NOT accept recom-
mendation forms that are not in a sealed envelope.
Instructions for Recommender: The below named student is applying for a study abroad scholarship through Governors
State University and has listed you as a reference. The GSU Study Abroad Scholarship Committee appreciates a frank
appraisal on your part of the applicant, particularly with regards to the applicant’s ability to successfully carry out studies
in a foreign environment. Please comment specifically on the applicant in terms of the following: a) academic suitability;
b) personal suitability; c) weaknesses; d) strengths e) linguistic preparation, if applicable; and any other factors relevant
to the applicant’s ability to participate successfully in a study abroad program.
Please write clearly or attach your typed comments on a separate sheet. Thank you for assisting us in the evaluation of this
student.
Note: The student’s study abroad scholarship application cannot be processed until references are returned. We would
therefore appreciate receiving your response as soon as possible. Please provide the form in a sealed envelope to the Office
of International Services in GMT 168 or email directly as an attachment to ois@govst.edu.
Study Abroad Scholarship Recommendation Form
(to be completed by student)
Name of Applicant: _________________________________________________________________________________________
GSU ID: ___________________________________________________________________________________________________
Email: ____________________________________________________________________________________________________
Program Destination: ______________________________________ Program Semester: ________________________________
Program Title: ______________________________________________________________________________________________
Program Dates: _____________________________________________________________________________________________
Names and Titles of References(s): ___________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Student Signature Date
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Study Abroad Scholarship
Recommendation Form and Instructions
11
Study Abroad Scholarship Recommendation Form
(to be completed by recommender)
First Name: ________________________________ Last Name: __________________________________________________
Institution/Business Name: __________________________________________________________________________________
Title: ______________________________________________________________________________________________________
Telephone: ( ) _____________________________________ Email:____________________________________________
Please answer all of the following questions.
1. How long and in what capacity have you known the applicant?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
2. If selected, this student will be required to make an adjustment to a challenging visiting abroad situation. The student’s
success in the program will be affected by this adjustment of staying in a foreign environment. Based on your knowledge of
the applicant, will you give us your opinion of student’s ability to make such adjustments?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
3. How would you describe the candidate in terms of maturity, sense of responsibility, reliability, honesty, and character?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
4. Please use this space to make any additional comments you want to make concerning the applicant’s qualifications for
the program. Attach an additional sheet if necessary.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Study Abroad Scholarship Recommendation Form
12
Please check the statement that you feel most accurately reflects your opinion of this student’s suitability for the program.
The student has my strong recommendation
I have minor reservations, but I am willing to recommend the student
I cannot recommend this student for the scholarship
___________________________________________________________________________________________________________
Signature Date
Please return this form either in sealed envelope to:
Attn: Study Abroad Scholarship Committee
Governors State University
1 University Parkway, GMT 168
University Park, IL 60484
or submit electronically to ois@govst.edu with “GSU Study Abroad Recommendation” in subject line.
Office of International Services
1 University Parkway, GMT 168
University Park, IL 60484
708.235.7611
Fax: 708.235.7372
ois@govst.edu
www.govst.edu/ois
Study Abroad Scholarship Recommendation Form
0717
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