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 International 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 Pronouns
__________________________ ______________________________ __________________ _____________________
Passport Number Country of Citizenship Expiration Date (mm/dd/yy) Place of Issue
Home University ___________________________________________________ Class standing 1
st
2
nd
3
rd
4
th
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 International 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
Courses in Claremont
Although we strongly recommend students select courses taught at Pitzer College, exchange students may take
undergraduate classes at other Claremont Colleges on a space available basis and with the permission of their
academic adviser. See https://mycampus2.pitzer.edu/ICS/Course_Schedule/Default_Page.jnz. Course offerings and
spaces are subject to change. There is no guarantee of enrollment in a particular class. Please list four courses that you
may be interested in registering for.
_____________________________________________________________ _____________________________________________________________
Dept. or Field Course Title Dept. or Field Course Title
_____________________________________________________________ _____________________________________________________________
Dept. or Field Course Title Dept. or Field Course Title
English Language Background
Are you a native speaker of English? Yes No
Have you completed four years in a high school whose primary language of instruction is
English? Yes No
Do you have an original and official TOEFL report with a score of more than 100 (internet-base TOEFL)
or more than 250 (computer-based TOEFL)? Yes No
What is your TOEFL score? _______
Note: A TOEFL score is not required for admission to the exchange program
Pitzer College, Office of Study Abroad, West Hall Q100, 1050 North Mills Avenue, Claremont, CA 91711
Telephone 909.621.8104 Email studyabroad@pitzer.edu
Pitzer College Exchange Application Essay 1
Name ____________________________________________________________________________
Respond to each of the following questions using this form. Be sure to address all parts of each question. The
maximum length for each essay is what will fit in the space provided. No hand-written responses please.
1. Describe in detail the structure of the Pitzer program. Given this structure, what are your strategies for engaging
members of the host culture and maximizing the learning that comes from such engagement? What are the benefits
to Pitzer College in having you as a community member?
Pitzer College, Office of Study Abroad, West Hall Q100, 1050 North Mills Avenue, Claremont, CA 91711
Telephone 909.621.8104 Email studyabroad@pitzer.edu
Pitzer College International Exchange Application Essay 2
Name ____________________________________________________________________________
2. Explain how your proposed study abroad experience will fit into your overall educational plan. Consider your
proposed major and your school's educational objectives in your response. What courses have you taken or will you
take to prepare yourself for study at Pitzer College? In what other ways have you begun to prepare or do you plan to
prepare?
Pitzer College, Office of Study Abroad, West Hall Q100, 1050 North Mills Avenue, Claremont, CA 91711
Telephone 909.621.8104 Email studyabroad@pitzer.edu
Pitzer College International Exchange Application Essay 3
Name ____________________________________________________________________________
3. Describe an intercultural experience you have had in which you had to adapt to unfamiliar people, customs, foods,
environments, etc. What did you learn from this experience and how might you apply what you learned to your time
at Pitzer College?
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 International 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 and International Programs
West Hall, Suite Q100, 1050 North Mills Avenue, Claremont, CA 91711
Telephone 909.621.8104 Email exchanges@pitzer.edu
Pitzer College International Exchange Application - Statement of Financial Responsibility
Pitzer College does not offer financial aid to international students.
Pitzer College is required by the United States Immigration and Naturalization Service to obtain evidence that all
applicants have adequate funds to pay for their educational and living expenses while studying at the college. If we do
not receive evidence of sufficient funds, we will not be able to issue the Form 1-20AB needed for the F-1 student visa.
Please check one of the following sources of support, enclose the documentation requested, and indicate the amount
guaranteed. (Our website, www.pitzer.edu lists the current educational costs.)
Personal Funds
Please enclose a bank statement, signed by an official of your bank, indicating sufficient funds available for any
expenses not covered by the exchange agreement
Parent/Sponsor
Please enclose a bank statement indicating the amount of funds available for any expenses not covered by the
exchange agreement and complete the statement of financial responsibility (below) to be signed by a parent or
sponsor.
Name of parent or sponsor _____________________________________________________________________________
Relationship to student ________________________________________________________________________________
Address _____________________________________________________________________________________________
____________________________________________________________________________________________________
This is to certify that I will be responsible for all expenses of the above named student during their studies at Pitzer
College.
Signature of parent or sponsor _______________________________________________ Date_____________________
I certify that all statements on this form are true and accurate and that funds will be provided as specified above.
Name _______________________________________________________________
Student’s 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
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
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 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 _______________________________________