Fillable Iss Application Form Fillable (Edmonds Community College)

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Iss Application Form Fillable (Edmonds Community College)

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1
EDMONDS COMMUNITY COLLEGE
INTERNATIONAL STUDENT APPLICATION
For addional informaon or quesons:
425.640.1518 | iss_desk@edcc.edu
edcc.edu/international
Family/Friend Emergency Contact Informaon (either in the U.S. or Abroad)
To apply, please submit:
Completed application.
A curren
t
ban
k statement showing a minimum of $19,505.92
(Must be in English on original official bank letterhead.)
Personal Informaon
New Student Transfer Student
Family Name/Surname
First Name
Middle Names
Please show your name as it appears on passport
Student Home Country Address
Address
City
State/Province
Postal Code
Country
Phone
Email
Date of Birth / /
Month Day Year
Do you have any dependent(s) applying with you?
Yes
No
If yes, submit dependent form and passport copy.
U.S. Address (if currently living in the US)
Address
City
State
Postal Code
US Phone
Country of Birth
Country of Cizenship
Nave Language
Name
Email
Address
Phone
Relaonship to you
Country
Quarter you plan to begin
Year:
Fall (Sept. - Dec.)
Winter (Jan. - March)
Spring (April - June)
Summer (July - Aug.)
OFFICE USE ONLY
Inial Agency
SID: 958 - 03 -
Applicaon received
Submit your application to issadmissions@edcc.edu,
fax 425.774.0455 or send by mail to:
Edmonds Community College
International Student Services
20000 68th Ave W, Lynnwood, WA 98036-5999, USA
Female
Male
A $50 non-refundable application fee.
A $40 non-refundable I-20 Mailing Fee
Copy of your valid passport.
English proficiency score (optional).
2
Agency/Advising Center Informaon (if applicable)
Where would you like your I-20 admission documents sent?
Which programs would you like to study? (Check all that apply)
Condional University Admission (Oponal)
Agency Name
Address
Agency Contact Person
Phone
Email
Pick Up (only the student, or if a minor, the parent/guardian
can pick up the I-20
We oer assurance of condional admission to the following universies upon admission to Edmonds Community
College. To qualify, students must meet the minimum requirements for admission to each university as indicated in the
leer. To receive an assurance of university admission leer, please mark ONE of the boxes below (list is subject to
change). For an up-to-date list of all universies that oer condional admission to Edmonds CC students, please check
our website at edcc.edu/internaonal/programs.
English as a Second Language (ESL)
High School Compleon Program
Academic Interest
Arizona State University
California State University, Northridge (CSUN) California
State University, San Marcos
Carroll College
Central Washington University (CWU)
City University of Seattle
Evergreen State University
Indiana University, South Bend
Indiana University, Purdue University, Indianapolis (IUPUI)
Les Roches International School of Hotel Management
Northern Arizona University (NAU)
Oklahoma City University (OKCU)
Oregon State University (OSU)
Portland State University (PSU)
San Francisco State University (SFSU)
Seattle University (SU)
Seattle Pacific University (SPU) University
of Massachusetts, Dartmouth University
of Nevada, Las Vegas (UNLV) University
of Oregon (UO)
University of Washington, Bothell (UWB)
University of Washington, Tacoma (UWT)
Washington State University (WSU)
Western Washington University (WWU)
Wichita State University
Name
Address
City
State/Province
Postal Code
Country
Phone
Email
College or University Transfer
(This program is for students who want to earn a high school diploma at Edmonds CC.)
English Language Proficiency:
Do you have an accepted English proficiency Score?
Yes
No
Proof of English language proficiency is required for direct acceptance to the high school or college programs.
Accepted English proficiency scores are IELTS: 5.0 in each, TOEFL: IBT 54, ELS 109 and, CAMBRIDGE: First Certificate Grades A, B, C.
Student's Home Country Mailing Address*
*$40 Mailing Fee is required per application
3
Housing Informaon
Current/Previous School in the United States
Fee Payment
Tuion Payment made by
2) What type of visa will you have while aending Edmonds CC?
If no, have you aended another U.S. school?
Yes
No
Last date of aendance
If you are transferring to Edmonds CC, we will send you an email to complete an online Transfer Eligibility Form upon
subming your transfer applicaon documents.
If you would like to arrange for an Edmonds CC Dormitory or Homestay, please submit a housing applicaon form and
non-refundable housing applicaon fee to housing@email.edcc.e
du. For more informaon, please check
edcc.edu/housing.
Student/Family
Agent (please submit aached Sponsorship Form on page 7)
Scholarship (please submit a scholarship leer and Sponsorship Form on Page 7)
Do you need support for a physical, mental health or learning disability ? Yes No
If Yes, Please explain:
For information on our services for students with disability, please check: www.edcc.edu/ssd
Disability Support
You are required to report all previous studies at another institution in the United States.
Are you currently in the United States? Yes
No
If yes
1) Wha
t type of visa do you currently have?
If attended, please submit all of your unofficial transcript(s) from U.S. school(s).
$50 non-refundable Application Fee (required)
$40 non-refundable I-20 Mailing Fee (required per application)
Check Money Order
Credit Card (please submit attached Credit Card Authorization Form on page 6)
Wire transfer to Edmonds CC
Beneficiary: Edmonds Community College | Account # 153 5011 418 47 | ABA: 125 000 105
SWIFT: USBKUS44IMT
Bank: U.S. Bank - James Village Branch | Bank address: 19420 Hwy 99 Lynnwood, WA 98036 USA
Please include the student name and SID.
4
Release of Informaon
Acknowledgement or Risks for O-Campus Trips and Acvies
Health Insurance
I understand and acknowledge that there is risk of injury to myself or my child by parcipaon in o-campus trips and
acvies. I further understand that it is voluntary to parcipate and that the college does not require parcipaon. I
hereby release Edmonds Community College and the State of Washington, its employees, ocers, agents and trustees,
my heirs, executors, administrators and assign any and all rights and claims for damages from any and all injuries that I or
my child may suer as a result of his/her voluntary parcipaon in trips and/or acvies.
I further agree to hold harmless and indemnify Edmonds Community College, its employees, ocers, agents and trustees
for any acon, claim, or proceeding iniated as a result of any injury suered by my child or any third party through his/
her parcipaon in any trips and/or acvies.
By signing this acknowledgement of risks for o-campus trips and acvies form, I verify that I have read its contents and
warnings and that I understand and agree to its terms.
Student Signature
Date
I give my permission to Edmonds Community College’s Internaonal Student Services (ISS) to release informaon to my
Agency Embassy Parents Other:
I do not give permission for Internaonal Student Services to release my student informaon.
Student Signature Date
All internaonal students are required to purchase LewerMark health insurance every quarter through Edmonds CC. This
health insurance does not cover vision and dental. For addional informaon please review
www.lewermark.com/edmondscc. I allow the Internaonal Student Services to provide my name, student ID number,
birthday, email and mailing address to Lewer Mark as requirement for insurance enrollment.
Student Signature
Date
Statement of Financial Responsibility
All internaonal applicants are required by law to show proof of nancial ability to live and study in the United States. This
secon must be completed and signed before admission. We must also receive a current bank statement (no more than
six months old) prior to admission.
The specied sources of my funds and the amount of U.S. dollars to be paid are provided by:
Personal: $ (Bank statement must be aached)
Family: $ (Bank statement must be aached)
Name on bank statement Relaonship to student
Scholarship: $ Name of scholarship
I will have sucient funds available to pay all the necessary expenses and tuion as stated in the costs/dates insert of
this applicaon packet. The source of these funds will connue through the duraon of my study at Edmonds Community
College.
Student Signature Date
5
Consent to Medical Care and Treatment of Minor Children
Waiver of Liability for Orientaon and O-Campus Trips and Acvies
I understand and acknowledge that there is risk of injury to myself or my child by parcipaon in o-campus trips and
acvies. I further understand that it is voluntary to parcipate and that the college does not require parcipaon. I
hereby release Edmonds Community College and the State of Washington, its employees, ocers, agents and trustees,
my heirs, executors, administrators and assign any and all rights and claims for damages from any and all injuries that I or
my child may suer as a result of his/her voluntary parcipaon in trips and/or acvies.
I further agree to hold harmless and indemnify Edmonds Community College, its employees, ocers, agents and trustees
for any acon, claim, or proceeding iniated as a result of any injury suered by my child or any third party through his/
her parcipaon in any trips and/or acvies.
By signing this acknowledgement of risks for o-campus trips and acvies form, I verify that I have read its contents and
warnings and that I understand and agree to its terms.
Student Signature
Date
Hospitals and physicians may be reluctant to treat or care for children without consent from parents or legal guardians.
This can cause problems if the child has a medical emergency and parents/guardians are not readily available to consent
to treatment.
Copies of this form will be made available to Internaonal Educaon Division, Internaonal Student Services, Housing,
and Student Programs oces of Edmonds Community College.
I,
,
the natural parent/legal guardian of
(Student),
authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a
licensed physician, or hospital when, in the sole discreon of the aending physician, such care, treatment and procedures
are immediately necessary or advisable in the interest of my child’s health and well-being, and it’s not advisable to take the
me to contact me in advance.
Under the circumstances set forth above, I elect not to be informed in advance of the nature and character of the
proposed treatment, its ancipated results, possible alternaves, and the risks, complicaons and ancipated benets
involved in the proposed treatment and the alternave forms of the treatment, including non-treatment.
Signature of Parent/Guardian
Date
UNDER AGE FORM
Required for under 18 years old
Student Name
Credit Card
Authorization
F
orm
I hereby authorize Edmonds Community College to charge:
Amount: USD
Amount in words:
dollars
Visa American Express
Discover
Security Code (3 digits on the back of the card):
On my credit card (check one)
Credit Card Number:
Expiration date (MM/YY): /
For (check all that applies):
Application Fee Only ($50 - non-refundable)
Mailing Fee ($40 - non-refundable)
Signature of Cardholder (as shown on your Credit Card) Date
Name of Student(s)
:
Student(s) ID No.
:
Person’s Name on the card:
Billing Address:
6
MasterCard
7
Edmonds Community College does not discriminate on the basis of race; color; religion; naonal origin; sex; disability; sexual orientaon; age; cizenship, marital, or veteran
status; or genec informaon in its programs and acvies. 15-16-ISS-013
Only to be lled if Agency pays for the student’s tuion
AGENCY/ORGANIZATION SPONSORSHIP FORM
Winter 2020 Spring 2020
Summer 2019
Name of organization:
Organization Contact Name:
Contact Email Address:
Student Name:
Student Identification Number (SID):
Effective (first quarter begin) in: Fall 2019
How many quarters will your organization pay for?
Please indicate billing by checking “Yes” or “No” for each item. Any item not checked will be charged directly
to the student.
REQUIRED FOR ALL PROGRAMS
Yes No
Yes No
Yes No
Yes No
Yes
No
Yes No
Yes No
Yes No
Yes No
Assessment Fee (one time only $50.00)
Bus Pass (First me $36.00, then $26.00 per quarter)
Edmonds CC Health Insurance ($327.99 per quarter)
COLLEGE / HIGH SCHOOL COMPLETION PROGRAM
Tuion (Maximum number of credits paid for per students:
Typical course load is 15 credits. More information at edcc.edu/tuition
Required Associated Student Fees
Lab fee*
Online/Hybrid fees*
IESL PROGRAM
Tuition (Required 20 credits, $3,318.20)
Grammar lab fee ($25.00 per quarter)
Housing fees (price vary, please visit edcc.edu/housing for more informaon)
Print Name and Title
Signature and Date
Edmonds CC scholarships are awarded as tuition waivers. The International Student Services office will adjust your invoice accordingly. There will not be any cash refunded to
students or the agency.
For any questions, please contact us at iss_fiscal@edcc.edu
Assessment/Union Building Fee, Sustainability Fee, Technology Fee, Comprehensive Fee
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Completed 23 July 2020

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