Nassau Community College
Study Abroad Application
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Thank you for your interest in Study Abroad at NCC.
*Please download, print, and complete this application in its entirety.
**When you email with your completed application,
please also include links to the programs you are most interested in.
You will receive a reply from the Study Abroad Advisor,
who will also schedule your first appointment.
General Information:
Full Legal Name: _________________________________________
NCC-ID (N#) _________________________________________
Home Phone: _________________________________________
Cell Phone: _________________________________________
NCC E-mail: _________________________________________
Personal Email: _________________________________________
Mailing Address: _________________________________________
City, State, Zip Code: _________________________________________
Date of Birth: ___________________________
Are you a U.S. citizen? ¨ Yes ¨ No
¨ No
Does your cell phone work internationally? ¨ Yes
Do you have a valid U.S. passport? ¨ Yes ¨ No
o If no, where do you hold citizenship? _________________________
o Do you hold dual citizenship? ¨ Yes ¨ No
§ If yes, what country? ____________________________
International Experience:
Nassau Community College
Study Abroad Application
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Have you ever visited the country where you plan to study? ¨ Yes ¨ No
If so, for what purpose or what length of time? ___________________________
Have you traveled, lived or studied abroad? ¨ Yes ¨ No
If yes, please describe _______________________________________________
Study Abroad Interests:
Country(ies) in which you wish to study ____________________________________
Program/Course(s) you wish to enter _____________________________________
Date you expect to enter the program (check and fill in)
¨ Fall 20 _____
¨ Winter 20 _____
¨ Spring 20 _____
¨ Summer 20 _____
Medical Information: (This information is intended for use solely in connection with the College’s
voluntary action effort to overcome the effects of conditions that may have resulted in limited
participation of qualified disabled persons. This information will be kept confidential. Refusal to
provide this information will not subject the applicant to adverse treatment. The information will be
used only in accordance with law and to provide appropriate services to those who may need them)
If you have a physical, hearing, visual or learning disability, please list below.
Is there any physical and/or mental condition which exists that may affect your performance?
¨ Yes ¨ No
If yes, please list and explain. ______________________________________________
Have you had recent surgery that may affect your participation in the program?
¨ Yes ¨ No
If yes, please explain. ______________________________________________
Are you currently using and prescription drugs that a medical professional needs to be aware of in case
of an emergency? ¨ Yes ¨ No
If yes, please list: _________________________________________________
Are you holding a medical insurance policy covering foreign travel? ¨ Yes ¨ No
(NOTE: It is most likely that the program you study abroad with will require that you purchase
supplemental insurance through them.)
Legal Information: The disciplinary records of all students applying for study abroad will be reviewed
through the Nassau Community College Office of Judicial Affairs. A review will be made of all infractions.
Nassau Community College
Study Abroad Application
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The Office of Judicial Affairs, in conjunction with the Office of International Education, will render a
decision based on the severity of the violation, to determine the student’s eligibility to participate in the
study abroad program.
Have you ever been convicted by federal, state, military or other law-enforcement authorities, for any
violation of any federal, state, county or municipal law, regulation or ordinance?
¨ Yes ¨ No
If yes, please explain. __________________________________________________________
As a participant of a study abroad program, I am subject to ALL “Code of Conduct” rules, as per the
Nassau Community College catalog. Usage or any involvement with illegal drugs or narcotics is cause
for immediate dismissal from the program and possible dismissal from Nassau Community College.
If I cause damage to the facilities being used by me during the time of my participation in this study
program, I understand that I will be held personally liable for any repairs required of the facility. In the
event that I do not reimburse the facility for said damages, I understand that Nassau Community
College will IMPOUND my school records (will not release them) until such time as restitution is made
by me.
If I leave the program voluntarily or am asked to leave at the request of the Program Director, I fully
understand that no refund will be made, and I am responsible for arranging and paying for return travel.
WAIVER OF LIABILITY: In the event that I elect to stay in (country) ____________________________
beyond (the end date of the program)_________________________, I understand that Nassau
Community College assumes no responsibility for any of my actions or the results therefrom. Therefore,
I understand that I will assume complete and total responsibility for all my actions beyond my
participation in (course/program) ____________________________.
Prior to final acceptance ALL applicants will be screened for requirements, i.e. GPA, completion of all
required remedial courses and minimum course requirement as stated in the program/course
ALL registrations are processed through the Office of International Education.
ALL bills must be paid in full upon receipt, (prior to departure) or students will be dis-enrolled without any
reimbursement of prior deposits.
The undersigned acknowledges that s/he has read the above, and that all statements made are correct
to the best of her/his knowledge.
Applicant’s Signature: ______________________________________ Date _______________
Parent’s or Guardian’s Signature (only necessary if the applicant is under 21 years of age):
_______________________________________ Date _______________
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