Stud
ent Registration of International Program
Thi
s form is to be submitted by students that are intending to undertake an international program that is not
coordinated by Charles Sturt University. Submission of this form does not guarantee academic credit or school
approval in relation to a program. This must be negotiated with Course Directors and documented within this form.
P RIVACY S TATEMENT
The personal information you provide in this form is governed by the Privacy and Personal Information Protection Act 1998, the
Health Records and Information Privacy Act 2002 and CSU’s Privacy Management Plan (the Privacy Legislation). Your
information will be collected by CSU Global to assess whether you are a suitable student to send overseas to a host institution
and to assess you for any travel or scholarship grants. If you are accepted into the CSU Global Exchange Program, your
information may be disclosed to authorised personnel at a host institution to assess your eligibility to secure a place at that host
institution.
Your personal information will not otherwise be made available to any other person or organisation for any other purpose without
your consent except where CSU may be legally required to do so. The provision of personal information in this form by you is
voluntary but if this information is not provided, CSU Global may not be able to assess your application in a timely manner.
You have a right of access to, and correction of, your personal and health information in accordance with the Privacy Legislation.
Please direct any enquiries you may have in relation to this matter to CSU Global. If you are unhappy with the way CSU has
handled or failed to handle your personal information, you may apply to have the matter reviewed by lodging a complaint with the
CSU Ombudsman.
I understand and acknowledge the information above.
Signature: . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . .
dd/mm/y
Name of Applicant
P ROGRAM D ETAILS
Program Type (please tick):
Conference
Research
Program hosted by another university or organisation
Short Term Program (including professional experience and external programs)
Internship/Placement (you must be receiving credit for placement hours)
Program Name/Details:
Provider/Host contact name:
Provider/Host contact number:
Destination Country/ies:
Scheduled dates and duration of program:
From: (DD/MM/YEAR)______________________to(DD/MM/YEAR) __________________________ Total days__________
Applicant’s current CSU course title:
(including major if applicable)
Applicant’s Faculty:
Applicant’s School:
Campus:
I am studying:
Full-time Part-time Internal Distance Education
Year of course commencement
at CSU:
CSU Global Independent Program Registration Page 1 of 4
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P ERSONAL D ETAILS
Student Number: Email:
Session phone number:
Mobile Number:
Home phone number:
Email:
Preferred postal address:
Date of Birth:
Country of citizenship:
Permanent resident of Australia:
□ Yes □ No
Are you an international student?
□ Yes □ No
* Please provide a copy of residency/student visa
E MERGENCY C ONTACT
I appoint the following person my designated Emergency Contact and authorise CSU and/or the Program Provider
to contact the person for or with information about me if a need arises. I have fully informed my Emergency Contact
regarding all aspects of my Independent Program, including the nature of possible risks.
Title: First Name:
Middle name/s: Last Name:
Primary contact number:
Secondary contact Number: Email:
Home address:
S
PECIAL
A
SSISTANCE
- P
ARTICIPANTS MAY BE REQUIRED TO MANAGE PHYSICALLY
CHALLENGING ACTIVITIES
, SUCH AS, BUT NOT LIMITED TO: CARRYING OWN LUGGAGE,
WALKING LONG DISTANCES AND STANDING FOR LONG PERIODS OF TIME
Please note: travel insurance may not cover some situations, including pre-existing medical conditions.
Providing this information can assist in ensuring necessary coverage
I understand it is my responsibility to research the level of services and facilities I may require in the destination
country and/or program
Yes No
A CADEMIC C REDIT OR R ECOGNITION
The program will be formally recognised by the university through:
Subject Credit (please specify). . . . . . . . . . . . . . . . . . . . . .
Practicum or Internship hours (please specify number of hours). . . . . . . . . . . . . . . . . . . . .
Other (Please Specify). . . . . . . . . . . . . . . . . . . . . . . . . . . .
No Credit
CSU Global Independent Program Registration Page 2 of 4
C ONSULTATION W ITH C OURSE D IRECTOR
I confirm that academic credit proposed by this student will be granted on successful program completion. I have
discussed with the applicant the requirements for receiving academic credit and acknowledge responsibility for
assessments/supervision to meet this requirement.
Date:
Signature of Course
Director:
Credit arrangement (List subjects for which credit is proposed including placement hours if required)
N OTIFICATION F ROM P LACEMENT U NIT ( for practicum and internship placements only)
I confirm that this applicant has registered and obtained approval for this program and is eligible to receive
academic credit. I have discussed with the applicant the requirements for this placement/internship and confirm that
compliance with practicum requirements is the responsibility of this office.
Date:
dd/mm/yy
Signature:
S TUDENT A CKNOWLEDGEMENT, D ECLARATION AND A GREEMENT
By inserting a against each of the following statements and signing where indicated, you confirm your understanding and
acceptance of the acknowledgements, declarations and agreements set out below and that CSU may rely on and enforce these
acknowledgements, declarations and agreements.
My Application
I declare that all the information submitted on this application is correct and complete.
I agree to advise CSU Global if there are any changes to the information I have given in this application.
My privacy
I acknowledge that I have read the Privacy Statement on the first page.
M
EDIA
R
ELEASE
A
GREEMENT
I understand that my testimonials/quotes and/or video footage/photographic images taken of me while on this
international program are for free and unrestricted use by Charles Sturt University and its agents in editorial,
advertising, educational and promotional material.
I understand that international copyright and intellectual property rights on these materials will remain the property of
Charles Sturt University who will be entitled to broadcast, publish or otherwise distribute these materials and any
product thereof in any way or manner that they see fit, in perpetuity.
My signature below signifies my approval, and I therefore have no further claims for compensation from Charles
Sturt University or its agents.
Student’s name:
Student’s signature:
DO NOT TYPE NAME
Student number:
Date:
dd/mm/yy
CSU Global Independent Program Registration Page 3 of 4
I consent to CSU Global disclosing my personal information to my designated Emergency Contact and any Australian or
foreign government agencies, for any purpose related to the protection of my safety and welfare.
My safety
I acknowledge that CSU does not warrant that the host country is a safe and suitable country for overseas travel and that my
decision to travel to a particular country or region is a personal one.
I acknowledge that I am required to register my travel online at
http://www.smartraveller.gov.au/ and Travel Tracker to keep
myself updated with the latest travel advice from this website.
I acknowledge that I am required to undertake the CSU Global Pre-Departure modules and agree to follow any relevant
directive issued by the Australian Embassy or High Commission or other Australian Government representative in the host country.
I understand that CSU can require my withdrawal from the program should it deem political instability and/or terrorist activities
in the region to be unsafe for me to remain in my host country.
My participation in the Program
I agree to advise CSU Global of any changes in the arrangements of my program.
I understand and accept that I must comply with the laws applicable in the host country at all times and that any failure to do so
may result in my expulsion from the host country at my own cost.
I understand that I am bound by, and must comply with, the
CSU Academic and Student General Misconduct Rule at all times
during my program.
I will not participate in any activity, including political activity, which might endanger the reputation of CSU, or undermine the
effectiveness or viability of the program.
I am responsible for applying for and obtaining any relevant visa associated with my travel.
I understand that it is my responsibility to negotiate and obtain approval from CSU for obtaining academic credit for study
completed.
My financial obligations
I understand that my participation in this program and associated travel is my sole responsibility and I assume all financial
responsibility, including debt, arising from such circumstance.
I am aware of the likely living cost of my stay overseas, and I have the necessary financial capacity to meet such costs for the
full duration of my exchange period.
I agree that I am responsible to ensure that my travel and medical insurance covers me for the total period of my travel
including any independent travel before, after and during the program.
My liabilities
I agree to indemnify CSU for any expenses, losses, damages and costs that I may sustain or incur as a result, whether directly
or indirectly, of any action arising from any failure by myself to obtain or maintain travel and medical insurance coverage.
I understand that CSU will not be liable in any way for injury, sickness or damage that I may suffer during my participation in
the program and/or resulting from the travel arrangements and any other related or incidental activities during this program.
General
I have sought and obtained appropriate advice on my responsibilities as set out in this Acknowledgement, Declaration and
Agreement.
I understand that this Acknowledgement, Declaration and Agreement cannot be modified or amended except in writing by
CSU.
I consent to the distribution of my personal and contact details to CSU divisions, external organizations and Government
departments in relation to this program. Please note if you are a participant in a government funded program part of the funding
agreement is that your personal details will be released to this body.
Signature: Date:
DO NOT TYPE NAME dd/mm/yy
You may be eligible for a Vice Chancellors Travel Grant in association with your international program. On
receipt of this registration form CSU Global will assess your eligibility and contact you in relation to additional
information you may need to provide in order to receive this grant.
CSU Global Independent Program Registration Page 4 of 4
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