Fillable International Exchange Visiting Student Application Fall2018 (Lock Haven University)

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International Exchange Visiting Student Application Fall2018 (Lock Haven University)

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  • 45 check-boxes
  • 184 other fields

Country of origin: US
File type: PDF

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200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 1
All international exchange and visiting students must be nominated by their home institution in order apply for admission
to Lock Haven University of Pennsylvania (LHUP). An incomplete application will not be considered.
Application Deadlines: Spring semester: November 1 and fall semester: April 1.
Instructions: The application packet is a fillable Adobe Acrobat PDF. Students must type all fields, print the document,
and scan back as a PDF to submit to John Gradel at jrg5874@lhup.edu. All forms except the pre-arrival form are due at
the time of application. Hand written and incomplete applications will not be processed.
1. Application Form – complete this form that provides necessary information about you.
2. Academic Planning Form - this form assists us with creating your student class schedule. You should complete
this with your academic advisor/professor/tutor. Please list all classes taken at your home university. The IIS can
also accept a copy of your transcript if translated into English.
3. International Exchange Student Registration Form – this form assists us with registering you in classes. You
should complete this with your academic advisor/professor/tutor. Please select up to 10 classes/courses you would
be interested in taking at LHU. Please note the following important items:
o The course catalog with unit descriptions lists all the possible class/courses that could be taught at
LHUP (http://www.lhup.edu/students/Registrar/coursecatalog/) – this is not the final fall or spring course
offerings. Students may not be enrolled in their preferred courses as some courses are not
offered every semester, although we will do our best to find acceptable substitutes. The final
schedule is posted after the deadline, so you may have classes in your list that are not offered.
o Students whose first language is not English, will be enrolled in one (1) class for a total of three (3) credits:
English Composition for International Students. If English is your first language, you will be not be placed into
English Composition for International Students unless requested on your form.
o Students will be registered for four (4) classes for a total of twelve (12) credits which is a typical workload for
students studying in the United States. One (1) of the classes is listed above leaving three (3) left to choose,
unless your first language is English, you will be placed in four (4) different classes.
o If you need to enroll in 15 credits for a total of 5 classes, please indicate on the application.
o Not all “1
st
choice” classes can be accommodated as the class may not be taught that semester. Please select
ten (10) different classes within the 100-200 level range.
4. Immigration Document (F-1 Visa: Form I-20 or J-1 Visa: DS-2019) Application– these forms provide us
information needed to provide you with the correct immigration documents to apply for a student visa. Proving you
have sufficient financial support to attend LHU is required, so supporting proof of financial documents should also
be attached to this application.
5. Residence Life Roommate Selection Form - this form assists with selecting your room.
6. Health Services History Form – this form is required to ensure you have the correct immunizations and to
provide Health Services with your health history should you need medical assistance.
7. Copy of Passport – Please attach a scanned copy of your passport photo page with biographical information
(name, country, place of birth, etc.). This is required to receive immigration documents.
8. English Language Proficiency Requirement: Please attach a scanned copy of scores from an English
Proficiency exam (ex: TOEFL, TOPIK) or letters stating you are proficient in the English language (countries where
English not the first language). This will be necessary to be issued a visa.
Any questions and applications should be directed to John Gradel at jrg5874@lhup.edu
regarding the international student exchange and visiting application.
International
Exchange & Visiting
Student Application
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 2
INTERNATIONAL STUDENT EXCHANGE & VISITING APPLICATION FORM
Name: Family/Surname ______________________________________________________________________
First ______________________________________ Middle Name (if none, use “X”) _____________________
City of Birth: _______________________________ Country of Birth: _________________________________
Country of Citizenship: _______________________
Plan to study for the semester (insert year): FALL 20___ OR SPRING 20___ OR ACADEMIC YEAR 20____ to 20____
Permanent Address - Home Country:
Address __________________________________________________________________________________
City __________________________________________ State/Province ______________________________
Postal Code____________________ Country Name _______________________________________________
Home Phone # (w/ country code) _____________________ U.S. Phone #_____________________________
Do you have a U.S. based phone #? If not, please check here: __________I do not have a phone # in the U.S.
College/University E-Mail: _____________________________ Personal E-Mail:__________________________
Emergency Contact - Home Country:
Name ____________________________________ Relationship _____________________________________
City __________________________________________ State/Province ______________________________
Postal Code____________________ Country Name _______________________________________________
Home Phone # (with country code if known) _____________________________________________________
E-Mail:____________________________________
I understand and certify that all information I have put into this application packet is accurate to the best of
my knowledge. I also realize that by submitting my information after the deadline, I might not get priority
with a housing assignment or class/course selection: (Please Print)
_________________________________________________________________________________________
Last or Family Name First Name
_________________________________________________________________________________________
Signature Date
Institute for International Studies OFFICE USE ONLY – Please do not write in this space
Approved Denied _________________________________ ____________
Signature Date
Student Notified (time and date): __________________________
Comments:
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200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 3
INTERNATIONAL STUDENT EXCHANGE & VISITING ACADEMIC PLANNING FORM
NAME: MAJOR OR INTENDED MAJOR: ___________________________
FIELD OF STUDY: ________________________________________________________
I intend to do the following while at LHU (check all that apply):
Take courses that will count toward degree requirements.
Take courses related to my major for my personal interests.
In the space below, list the TITLES of courses in which you have enrolled prior to attendance at LHU.
If more space is needed please feel free to use back of form or another sheet.
1. _______________________________________________________________________________
2. _______________________________________________________________________________
3. _______________________________________________________________________________
4. _______________________________________________________________________________
5. _______________________________________________________________________________
6. _______________________________________________________________________________
7. _______________________________________________________________________________
8. _______________________________________________________________________________
9. _______________________________________________________________________________
10. _______________________________________________________________________________
11. _______________________________________________________________________________
12. _______________________________________________________________________________
13. _______________________________________________________________________________
14. _______________________________________________________________________________
15. _______________________________________________________________________________
Highest Math Level Achieved (i.e. Algebra II, Trigonometry, Calculus, Linear Functions…) **MUST LIST**
__________________________________________________________________________________
__________________________________________________________________________________
**********************************************************************************
I am aware that course offerings at LHU fluctuate and that it may be necessary to adjust my courses accordingly.
Also, I understand that my major department has final authority over what classes are to be taken at LHU to fulfill
any requirements. I am also conscious that I may need to adjust my schedule once I arrive at LHU.
______________________________________________________________________
Student’s Signature (Month/Day/Year) Date
_________________________________________________________________________________________
Home Institution Advisor’s Signature (Month/Day/Year) Date
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signature
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signature
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200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 4
INTERNATIONAL STUDENT EXCHANGE & VISITING REGISTRATION FORM
This form is to be used by international exchange and visiting students representing partner universities with which LHU
maintains formal exchange ties. Non-exchange or visiting students interested in seeking a baccalaureate or
graduate degree at LHU must submit a formal application to the Office of Admissions.
Application deadlines can be found on the Institute for International Studies website under exchange students. Return
this form with the rest of your international exchange application.
PLEASE COMPLETE ALL INFORMATION:
Plan to study for the semester (insert year): FALL 20___ OR SPRING 20___ OR ACADEMIC YEAR 20____ to 20____
Personal Information
Name Family_________________________First______________Middle__________________
Home College/
University
Major Study:
Home Address Street__________________________________________________________________
City_____________________________ State/Providence________________________
Postal Code_______________________ Country_______________________________
Country of Birth
Country of
Citizenship
High School Graduation Date:
High School Name:
Home Phone (include country code) -
Cell/Mobile
Phone
(include country code) -
Gender Male _____ Female ________
Married/Single
(optional)
Birthday
(Month/Day/Year)
Personal E-mail
Address
United States Department of Education Questions
What is your
ethnicity?
Hispanic or Latino Not Hispanic or Latino
What is your
race? Mark one or
more races to indicate
what you consider
yourself to be.
White Black or African American Asian
American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
Course Choices
If you need help in selecting appropriate courses and alternates, contact your home institution International Office (advisor, tutor, or
professor) or the Institute for International Studies at Lock Haven University. All courses must be selected from our LHU Course
Catalog: http://www.lhup.edu/students/Registrar/coursecatalog/. It is important that you make different 1
st
and 2
nd
choices.
Exchange students are required to take a minimum of 12 credit hours of courses per semester to retain full-time
status; generally four courses valued at 3 credit hours each. *YOU MUST LIST COURSE NAME AND NUMBER*
1
st
Five Different Choices (Course # & Name)
Ex: COMM100 - Introduction to Communication
2
nd
Five Different Choices (Course # & Name)
Ex: COMM100 - Introduction to Communication
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 5
IMMIGRATION DOCUMENT (F-1 VISA: FORM I-20 or J-1 VISA: DS-2019)
APPLICATION FOR EXCHANGE OR VISITING INTERNATIONAL STUDENT
PART 1: Personal Information
1. Name as spelled in your passport:
_________________________________________________________________________________
Family/Last Name First Name Middle Name
Enter your name exactly as shown in your passport.
2. Date of Birth: Month______ Day ______ Year _______
3. Gender:
□ Male □ Female (Please check one)
4. Country of Birth: ___________________________________________________
5. Country of Citizenship: ______________________________________________
6. Country of Permanent Residence: ____________________________________
7. City of Birth (as may be noted in your passport): _________________________________________
8. Permanent Address in Home Country
__________________________________________________________________________________
Number and Street
__________________________________________________________________________________
City Province /State/Territory Postal Code
9. Address in the United States (if known)
__________________________________________________________________________________
Number and Street
__________________________________________________________________________________
City Province/State/Territory Postal Code
10. U.S. Telephone #_____________________ Email__________________________________
11. Dependents: A student wishing to have his/her family member(s) accompany him/her must document
the following amounts for each family member per calendar year of study: Spouse: $12,700 per calendar year;
each child: $3,036 per calendar year. If you are bringing your family, please let John know at
jrg5874@lhup.edu know when you e-mail him regarding estimated costs on the next page.
□ I plan to come without dependents
□ The following dependents will accompany me (list names and relationships):
1. ______________________________________________________________________________________________________
Name (Family/First/Middle) Date of Birth (M/D/Y) Country of Birth
________________________________________________________________________________________________________
Country of Citizenship Gender Relationship to you (Spouse/Child)
2. ______________________________________________________________________________________________________
Name (Family/First/Middle) Date of Birth (M/D/Y) Country of Birth
________________________________________________________________________________________________________
Country of Citizenship Gender Relationship to you (Spouse/Child)
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 6
PART 2:
(If you are in the United States, now, please complete this section. If not, continue to Part 3.)
What is your Immigration Status? You may apply regardless of your immigration status.
□ F-1 or J-1 What is your SEVIS ID number? N________________________________
What is the purpose of your requested Form I-20 or DS-2019? (Check one)
□ School Transfer
□ Change education level or program at Lock Haven University
□ Reinstatement to F-1 Status
□ Another Status: Which one? ___________________
Before we issue your Form I-20 or DS-2019, we want to advise you. Please make an appointment to
see John Gradel ((jrg5874@lhup.edu) in the Institute for International Studies at LHU.
Do you plan to travel outside the U.S. before school starts?
□ Yes Tell us how you would like to get your Form I-20 or DS-2019 in Part III.
□ No If you are F-1 or J-1, you will receive school transfer or other instructions.
If you hold another status, you must meet with IIS staff before a new Form I-20 or DS-2019
can be issued.
Part 3
If you are NOT in the United States now, complete this section.
DID YOU RECENTLY ATTEND SCHOOL IN THE U.S. IN F-1 or J-1 STUDENT STATUS?
□ NO
□ YES If yes, what was the last date of your attendance? ________________________
(Month/Day/Year)
If you attended a U.S. school last term and traveled home on holiday between academic terms, you
are considered a “School Transfer” and need to have your record transferred to us before your Form
I-20 or DS-2019 may be issued. Please contact your international student advisor at your previous
school immediately to authorize the release of your SEVIS record to us.
RECEIVING YOUR I-20 or DS-2019:
Your Form I-20 or DS-2019 will be sent standard airmail to your home university’s international office
where they will provide you with the immigration documents, along with your acceptance packet
(usually should arrive a month and a half after the deadline).
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 7
PART 4
Student’s Statement of Financial Support
Part IV part has to be completed in full and needs supporting documents as noted below.
What level of education will you be pursuing? _______________________________________________
(Visiting or Exchange/Major)
What are your estimated annual costs?
Each exchange or visiting student attending LHU will be billed a different cost. Please e-mail John Gradel at
jrg5874@lhup.edu to obtain an estimated cost. Please indicate which University you are from, how long you
are studying for (semester or year), and if you are going to be an exchange or visiting student. Once
receiving this information, please proceed to complete the rest of the form and attach supporting documents.
Total Estimated Cost:
How will you be funded for each semester or year of your program of study?
Please check off your funding sources below and indicate how much will be provided or available
to you every year:
Source(s) of my support (check all that apply): $ Amount
□ Personal Funds:
The amount available to me from my own resources
_________________
□ Funds from this school:
renewable every semester/year
Type: ____________________________________________________
_________________
□ Cash Funds from a Sponsor:
to be given to me every semester/year
Sponsor’s name: ___________________________________________
_________________
□ Cash Funds from a Sponsor:
to be given to me every semester/year
Sponsor’s name:
___________________________________________ _________________
□ Cash Funds from a Sponsor:
to be given to me every semester/year
Sponsor’s name:
___________________________________________ _________________
Total amount available to me:
This amount must greater than or equal to your minimum annual costs.
The following documents are attached to this application to prove my funding:
(All documents must be attached in the scanned PDF, due at the application deadline.)
My personal documents: Funds from the School:
□
Bank/asset statement
□
Award letter
□
Proof of income/assets
□
Copy of contracts
Cash Sponsor’s documents:
□
Affidavit of Support
□
Proof of Income
□
Bank Statement
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 8
SPONSOR’S AFFIDAVIT AND EVIDENCE OF ANNUAL CASH SUPPORT
WHAT DOES THIS AFFIDAVIT MEAN?
By completing this affidavit, you are swearing to the U.S government that you will provide this student with a
specific amount of money from your own financial resources
for every semester or year
he or she is going to
study at Lock Haven University and live in the U.S. You are also proving that you can afford the support you
are promising with the documents you have attached.
Before signing it, it is important to understand that you are making a financial commitment to the student
which should not be broken. Sponsors who fail to provide the promised support force students to drop out of
school and cause pain and suffering. Do not expect that the student will be able to help support the costs
through employment. Employment is strictly controlled by the U.S. Department of Homeland Security and very
limited.
HOW TO COMPLETE THIS FORM:
Fill this form out in English (or have it officially translated). Promise only the amount of money you are
able to give. The most common reason we reject affidavits if that we do not believe a sponsor can
afford to give as much as promised.
Sign and date the affidavit.
Attach the supporting evidence listed below. The affidavit will not be accepted without the required
supporting evidence. You will need to keep the originals to present at the United States Consulate or
Embassy at the visa interview.
SUPPORTING EVIDENCE REQUIRED FROM YOU OR A SPONSOR:
1. Proof of income (
any of the following
) with most recent pay stub:
Investment statements for the last six months,
or
Income tax returns or receipts,
or
Pay stubs for last six months,
or
2. Bank statement in your name only. A monthly statement of balances and deposits.
If another person’s name appears on your bank statement, that person must complete a separate
affidavit. A letter from a bank officer will not be accepted.
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 9
THIS IS MY SWORN PROMISE OF CASH SUPPORT
I, _____________________________________________, promise that I can and will give
My name
______________________________________________ no less than U.S. $ __________________
Full name of student
in cash for EVERY SEMESTER OR YEAR of the student’s program of study at Lock Haven University.
My relationship to the student is______________________________________________________________
Parent, spouse, brother/sister, friend
My address is:
________________________________________________________________________________________
________________________________________________________________________________________
Telephone _____________________ Fax____________________ Email______________________________
The following persons are fully or partially dependent upon me for their support. (Do not include the student
named above).
_________________________________________________________________________________________
Name Relationship to me Age
_________________________________________________________________________________________
Name Relationship to me Age
Name of my employer: _____________________________________________________________________
Annual salary: _____________________(USD) Other income: _______________________________ (USD)
My proof of income and bank statements are attached: □ Yes □ No
I swear that the information I have provided above is true and correct
____________________________________________________________
Signature of Sponsor
___________________________
Today’s Date
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200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 10
LOCK HAVEN UNIVERSITY OF PENNSYLVANIA
R
OOMMATE SELECTION FORM
Welcome to the Student Life/Housing Department at Lock Haven University of Pennsylvania (LHUP). We ask
that you complete this compatibility profile form in its entirety and return it the Institute for International
Studies with the rest of your exchange packet by the due date indicated on the Institute for International
Studies website. The Student Life/Housing Office uses this information in the roommate/room assignment
process.
Please Print Clearly and Legibly in English
HOME INSTITUTION NAME:
_______________________________________________________________________________________
N
AME: Family____________________ First _______________________middle initial (if none, use “X”) ____
G
ENDER: Male Female PHONE # (INCLUDE COUNTRY CODE):
____________________________________
P
ERMANENT ADDRESS (HOME COUNTRY): Address _________________________________________________
City ________________________________ State/Province _______________________ Postal
Code_________________
Country Name ______________________________________
Do you have any disabilities or special needs which could affect housing accommodations? Yes No
If yes, please specify: ________________________________________________________________________________
__________________________________________________________________________________________________
All LHUP residence hall rooms and common areas are designated as Non-Smoking. Students and guests may choose to smoke off
campus, while respecting others and Hall Council Guidelines. Even though every room will be non-smoking, there are still students who
cannot tolerate a roommate who smokes (even outside of the halls).
Please answer the following: I would be bothered by a roommate who smokes (Select One): Yes No
Please Note: Very Important
All Hall, Floor and/or Roommate Preferences are honored whenever possible on a first-come, first-serve basis.
The earlier you turn in your application to the Institute for International Studies, the more likely that Student
Life/Housing Office can accommodate your wishes. Not all requests can be honored.
LHUP allows students who are having unsolvable roommate problems to change rooms providing that there are open
spaces in which to move.
LHUP International Exchange Student Requirement: International exchange students admitted to LHUP must
live on-campus when they are enrolled at LHUP.
HOUSING ASSIGNMENT INFORMATION WILL BE PROVIDED
DURING INTERNATIONAL STUDENT ORIENTATION.
HALL/FLOOR PREFERENCE (PLEASE SELECT ONE):
All international students are housed in a traditional double (2 beds, 1 for each occupant) in Woolridge Hall. Woolridge
has a kitchen on the first floor and community based bathrooms. Woolridge is comprised of 10-15% international
students with the remaining being United States students. Woolridge is a co-ed (men and women) residence hall, but
only same sex/genders room together. For more information visit the website at
http://www.lhup.edu/housing/woolridge_hall.htm.
R
OOMMATE PREFERENCES: (Only mutual requests will be honored)
If you know of a United States student studying at LHU and would like this person to be your roommate:
_______________________________________________
Name (First and Last): _____________________________________ Address: _________________________________
**All roommate requests must be returned to the Institute for International Studies no later than November 1 for spring
semester and no later than April 1 for fall semester. All hall, floor, and/or roommate preferences are honored whenever
possible on a first-come, first-served basis.
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 11
INTERNATIONAL STUDENT HEALTH HISTORY FORM
In order to enroll in classes at Lock Haven University, you must complete the Health History Form. This
provides doctors/nurses with information should you need medical treatment. Please complete all sections of
this form. You will need to have a physical check-up by a licensed doctor/nurse/physician. Please make sure
the doctor/nurse/physician fills out the appropriate page and signs it. Please send the completed Health
History Form to the Institute for International Studies with your completed application.
Part 1: Personal information to be completed by the student. Please type this information.
Part 2: Personal health history to be completed by the student. Please type this information.
Part 3: Physical examination to be completed by a licensed doctor/nurse/physician and signed.
Part 4: Required immunizations/vaccines to be completed by student or doctor/nurse/physician.
Part 5: Required tuberculosis information to be completed by student or doctor/nurse/physician.
Consent/Authorization for Treatment: I certify that the information provided on this Medical Health Form
is true and complete to the best of my knowledge. I also realize that this information is confidential and for
use by the Heath Service staff. I give permission for myself to be evaluated, diagnosed, and treated by Lock
Haven University Health Services under the direction of a nurse. It should be understood that under certain
circumstances, or emergencies, I may be referred to an area hospital, diagnostic testing facility, or medical
specialist for evaluation, diagnosis, and/or treatment. I understand that any costs for these services are
assumed by me and/or my insurance carrier.
Student Signature: Date:
Family Name: ______________________ First Name: _____________________ Date of Birth: (___/___/___)
M D Y
Part 1: Personal information completed by the student.
I am an (select one): ___Exchange Student ___Matriculating Full-
T
ime Student
Semester of Study: FALL 20___ Spring 20___ OR ACADEMIC YEAR 20___ TO 20___
Surname: First Name, Middle Initial:
Home Address: City:
State/Country: Postal Code: Phone Number:
Date of Birth: (Month/Day/Year)
Male Female
Name of Emergency Contact: Phone Number (include country code):
Relationship to Student: Emergency Contact’s Email Address:
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 12
Family Name: ______________________ First Name: _____________________ Date of Birth: (___/___/___)
M D Y
Part 2: Personal health history completed by the student. Please complete all questions
Allergies: Medications:
Have you ever had: Yes No Have you ever had: Yes No Have you ever had: Yes No
Hepatitis A,B or C Asthma
Attention Deficit Disorder
HIV Pneumonia Bipolar Disorder
Mononucleosis Sinusitis Depression
Chicken Pox Seasonal Allergies Anxiety
Measles (Rubeola) Shortness of Breath Panic Attacks
Mumps Unexplained Fainting Suicide Attempts
German Measles
(Rubella)
Thyroid Disease Learning Disability
Tuberculosis Diabetes Eating Disorder
Rheumatic/Scarlet Fever
Hypoglycemia Psychiatric problems
Gallbladder Disease Arthritis
Alcohol/Drug Dependency
Gastroesophageal Reflux
Disease (GERD)
Back Problems
Female
Liver Disease Headaches Ovarian Cysts
Polyps (Colon) Seizure Disorder Breast Disease
Heart Disease, Murmur, or
Infection
Cancer Past Pregnancy
High/Low Blood Pressure
Tumor/Cyst Irregular Periods
Chest Pain/Discomfort Anemia Excessive Cramping
Eye Disorders/Disease Physical Disabilities Male
Ear Disorders/Disease Any Surgeries Hernia
Dental Disorders Broken Bones Testicular Problems
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 13
Part 3: Physical examination to be completed by a licensed doctor/nurse/physician & signed.
Medical Evaluation Normal Abnormal Findings Explained Initials
BP:____/____
TPR
Height: Weight:
Head, Face, Neck, and Scalp
Eyes (acuity) and Ophthalmic
Exam
Ear, Nose, Throat, Sinuses,
Mth
Lungs and Chest
Heart
Abdomen
Skin
Neurological
G-U
Menstrual History (if
li bl )
Musculoskeletal
Neck
Back/shoulder/arm
Elbow/Forearm
Wrist/Hand/Fingers
Hip/Thigh
Knee
Leg/Ankle
Foot/Toes
REQUIRED FOR ATHLETES
Heart Murmur
Femoral Pulses to Exclude Aortic
Corarctation
Physical Stigmata
Brachial Artery BP Sitting
Piti
Doctor/Physician Information (MUST BE COMPLETE)
Doctor/Physician Signature: Date: (M/D/Y) Print Name:
Address: City/Providence:
State/Country: Postal Code: Phone Number:
MANDATORY FOR ATHLETES ONLY
Medically cleared for sports
Yes No
Doctor/Physician Signature: Date: (M/D/Y)
Family Name: ______________________ First Name: _____________________ Date of Birth: (___/___/___)
M D Y
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 14
Part 4: Required immunizations/vaccines to be completed by the student or licensed doctor/nurse/physician.
M / D / Y
Tdap (Tetanus Diphtheria Pertussis) (1 shot within the last 10 years) ___/___/___
Meningitis (1 shot within the last 5 years) ___/___/___
MMR (Measles, Mumps, Rubella) (2 shots) ___/___/___ ___/___/___
Varicella (Chicken Pox) (2 shots OR age at time of disease) Age: ___/___/___ ___/___/___
Hepatitis B (3 shots) ___/___/___ ___/___/___ ___/___/___
Polio (IPV) (4 shots) ___/___/___ ___/___/___ ___/___/___ ___/___/___
M / D / Y M / D / Y M / D / Y M / D / Y
Part 5: Required tuberculosis information to be completed by student or licensed doctor/nurse/physician.
Please answer the following questions:
Have you ever had close contact with persons known or suspected to have active TB disease? Yes No
Were you born in one of the countries listed below that have a high incidence of active TB disease? Yes No
(If yes, CIRCLE country)
Afghanistan Comoros Iraq Namibia Somalia
Algeria Congo Japan Nepal South Africa
Angola Cote d’Ivoire Kazakhstan Nicaragua Sri Lanka
Argentina Demo. Rep. of Korea Kenya Niger Sudan
Armenia Demo. Rep. of Congo Kiribati Nigeria Suriname
Azerbaijan Djibouti Kuwait Pakistan Swaziland
Bahrain Dominican Republic Kyrgyzstan Palau Syrian Arab Republic
Bangladesh Ecuador Lao Demo. Rep. Panama Tajikistan
Belarus El Salvador Latvia Papua New Guinea Thailand
Belize Equatorial Guinea Lesotho Paraguay
Former Yu
g
oslav Rep. of
Macedonia
Benin Eritrea Liberia Peru Timor-Leste
Bhutan Estonia Libyan Arab Jamahiriya Philippines Togo
Bolivia Ethiopia Lithuania Poland Tunisia
Bosnia & Herzegovina Fiji Madagascar Portugal Turkey
Botswana Gabon Malawi Qatar Turkmenistan
Brazil Gambia Malaysia Rep. of Korea Tuvalu
Brunei Darussalam Georgia Maldives Rep. of Moldova Uganda
Bulgaria Ghana Mali Romania Ukraine
Burkina Faso Guam Marshall Islands Russian Fed. United Rep. of Tanzania
Burundi Guatemala Mauritania Rwanda Uruguay
Cambodia Guinea Mauritius St. Vincent and the Grenadines Uzbekistan
Cameron Guinea-Bissau Mexico Sao Tome and Principe Vanuatu
Cape Verde Guyana Micronesia Senegal Venezuela
Central African Rep. Haiti Mongolia Seychelles Vietnam
Chad Honduras Morocco Sierra Leone Yemen
China India Mozambique Singapore Zambia
Colombia Indonesia Myanmar Solomon Islands Zimbabwe
Family Name: _________________ First Name: _____________________ Date of Birth: (___/___/___)
M D Y
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 15
Part 5: Continued required tuberculosis information
Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2010. Countries with incidence rates of ≥
20 cases per 100,000 population. For future updates, refer to http://apps.who.int/ghodata
Have you had frequent or prolonged visits* to one or more of the countries listed above with a high prevalence of TB disease?
(If yes, CHECK the countries, above)
Yes No
Have you been a resident and/or employee of high-risk congregate settings (e.g., correctional facilities, long-term care facilities,
and homeless shelters)? Yes No
Have you been a volunteer or health-care worker who served clients who are at increased risk for active TB disease?
Yes No
Have you ever been a member of any of the following groups that may have an increased incidence of latent
M. tuberculosis
infection or active TB disease – medically underserved, low-income, or abusing drugs or alcohol? Yes No
If the answer is YES to any of the above questions, Lock Haven University requires that you receive TB testing as soon as
possible but at least prior to the start of the subsequent semester).
If the answer to all of the above questions is NO, no further testing or further action is required.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
TUBERCULOSIS (TB) RISK ASSESSMENT (to be completed by nurse/physician/doctor
provider)
Clinicians should review and verify the information above. Persons answering YES to any of the questions in Part K are
candidates for either
Mantoux tuberculin skin test (TST) or Interferon Gamma Release Assay (IGRA), unless a previous positive test has been
documented.
History of a positive TB skin test or IGRA blood test? (If yes, document below) Yes No
History of BCG vaccination? (If yes, consider IGRA if possible.) Yes No
1. TB Symptom Check
Does the student have signs or symptoms of active pulmonary tuberculosis disease? Yes No
If No, proceed to 2 or 3
If yes, check below:
____ Cough (especially if lasting for 3 weeks or longer) with or without sputum production
____ Coughing up blood (hemoptysis)
____ Chest pain
____ Loss of appetite
____ Unexplained weight loss
____ Night sweats
____ Fever
Proceed with additional evaluation to exclude active tuberculosis disease including tuberculin skin testing, chest x-ray, and
sputum
evaluation as indicated.
2. Tuberculin Skin Test (TST)
(TST result should be recorded as actual millimeters (mm) of induration, transverse diameter; if no induration, write “0”.
The TST interpretation should be based on mm of induration as well as risk factors.)**
Date Given: M____/D____/Y_____ Date Read: M____/D____/Y_____
Results: _____mm of induration Interpretation: ____positive
____negative
Family Name: _________________ First Name: _____________________ Date of Birth: (___/___/___)
M D Y
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 16
Please Note: Please keep a copy of this form, and any attachments, for your records
Family Name: ______________________ First Name: _____________________ Date of Birth: (___/___/___)
**Interpretation guidelines
>5 mm is positive:
Recent close contacts of an individual with infectious TB
Persons with fibrotic changes on a prior chest x-ray, consistent with past TB disease
Organ transplant recipients and other immunosuppressed persons (including receiving equivalent of >15 mg/d of
prednisone for >1 month.)
HIV-infected persons
>10 mm is positive:
recent arrivals to the U.S. (<5 years) from high prevalence areas or who resided in one for a significant* amount of
time
injection drug users
mycobacteriology laboratory personnel
residents, employees, or volunteers in high-risk congregate settings
persons with medical conditions that increase the risk of progression to TB disease including silicosis, diabetes mellitus,
chronic renal
failure, certain types of cancer (leukemias and lymphomas, cancers of the head, neck, or lung), gastrectomy or
jejunoileal bypass
and weight loss of at least 10% below ideal body weight.
>15 mm is positive:
persons with no known risk factors for TB who, except for certain testing programs required by law or regulation,
would otherwise not be tested.
* The significance of the travel exposure should be discussed with a health care provider and evaluated.
Management of Positive TST or IGRA
All students with a positive TST or IGRA with no signs of active disease on chest x-ray should receive a recommendation to be
treated for latent TB with appropriate medication. However, students in the following groups are at increased risk of progression
from LTBI to TB disease and should be prioritized to begin treatment as soon as possible.
Infected with HIV
Recently infected with
M. tuberculosis
(within the past 2 years)
History of untreated or inadequately treated TB disease, including persons with fibrotic changes on chest radiograph
consistent with prior TB disease
Receiving immunosuppressive therapy such as tumor necrosis factor-alpha (TNF) antagonists, systemic corticosteroids
equivalent to/greater than 15 mg of prednisone per day, or immunosuppressive drug therapy following organ
transplantation
Diagnosed with silicosis, diabetes mellitus, chronic renal failure, leukemia, or cancer of the head, neck, or lung
Have had a gastrectomy or jejunoileal bypass
Weigh less than 90% of their ideal body weight
Cigarette smokers and persons who abuse drugs and/or alcohol
•Populations defined locally as having an increased incidence of disease due to
M. tuberculosis
, including medically underserved,
low-income populations
________Student agrees to receive treatment
________Student declines treatment at this time
200 Ulmer Hall – Lock Haven University of Pennsylvania – 570.484.2140 – Institute for International Studies 17
INTERNATIONAL STUDENT EXCHANGE & VISITING FURTHER REQUIREMENTS
COPY OF PASSPORT
Copy of Passport – Please attach a scanned copy of your passport photo page with biographical information
(name, country, place of birth, etc.). Please ensure the scanned copy is legible and can be read easily. This is
due at the time of the application as this form is needed to create immigration documents. Without the copy of
the biological page in the passport, immigration documents cannot be issued. Please sure your passport will
be valid during your planned stay in the United States, otherwise you should get this document renewed prior
to coming to the United States.
COPY OF ENGLISH LANGUAGE PROFICIENCY
Copy of English Language Proficiency Requirement – Please attach a scanned copy of your scores from
an English Proficiency exam (ex: TOEFL, TOPIK, etc.) or letters stating you are proficient in the English
language (countries where English not the first language). If submitting a letter, this should come from a
English as a Second Language (ESL) professor/tutor or from your International Office. This will be necessary
to be issued a visa at the embassy/consulate.
FINAL INSTRUCTIONS:
Any questions regarding the application should be sent to
John Gradel, Assistant Director of the Institute for International Studies.
Completed applications should e-mailed in one (1) PDF format to
John Gradel, Assistant Director of the Institute for International Studies.
Please do not send multiple attachments, as they may get lost in transmission.
NOTICE OF ACCEPTANCE:
Upon receipt of your completed application, your application will be processed in a timely manner. Upon
acceptance, your schools International Office will receive your acceptance packet that will include an
acceptance letter, immigration document, pre-arrival form, and pre-arrival guide with instructions of when to
arrive, what to bring, and a check-list of items to do prior to arrival.
Contact Information:
John Gradel, Assistant Director of the Institute for International Studies
E-mail: jrg5874@lhup.edu
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International Exchange Visiting Student Application Fall2018 (Lock Haven University)

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Completed 25 July 2020

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