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Study Abroad Application
PROGRAM & DESTINATION COUNTRY: ______________________________________________
EXCHANGE HOST SCHOOL OVERSEAS: _______ __ _________
FIELD SCHOOL LOCATION ABROAD: ______ ____ NIC DEPARTMENT _ _
PRACTICUM OR INTERNSHIP LOCATION ABROAD _______ _________________
EXPECTED DATES ABROAD:
________________________
TO:
M
F
N/A
GPA: ______________________
FIRST & LAST NAMES (EXACTLY AS THEY WILL APPEAR ON YOUR PASSPORT):
(FIRST NAME) (LAST NAME)
DATE OF BIRTH: ______/______/________
DAY MONTH YEAR
CONTACT INFORMATION: (TICK EACH BOX AS YOU COMPLETE IT)
CORRECT MAILING ADDRESS ON MYNIC? CORRECT PHONE NUMBER ON MYNIC?
I HAVE PROVIDED AN ALTERNATE PHONE NUMBER OR CELL ON MYNIC. YES NO
I
UNDERSTAND THAT ALL EMAIL CORRESPONDENCE WILL COME THROUGH MYNIC STUDENT EMAIL.
NIC STUDENT NUMBER:
START AT NIC: YEAR: ______ FALL/WINTER
PROGRAM:
WILL YOU BE TRAVELLING ON A CANADIAN PASSPORT? YES NO IF NO, FROM WHICH COUNTRY? ___ ____ ____________
DO YOU CURRENTLY HAVE A PASSPORT? YES NO
IF YES, LIST THE PASSPORT NUMBER AND EXPIRY DATE: ______
IF NO, DATE BY WHICH YOU EXPECT TO APPLY: _________________________________
Passports must be valid for six months past your intended date of return. We require a copy of the information page for our files. If you don’t have a
valid passport, submit the application form and provide us with a copy of the information page of your passport when you receive it.
Have you ever been convicted of a criminal offence for which you have not been pardoned? (this may affect your ability to travel to, or
transit, some countries) yes no
MAY WE RELEASE YOUR NAME AND EMAIL ADDRESS TO PRESENT OR POTENTIAL PARTICIPANTS? YES NO
PLEASE READ THE FOLLOWING BEFORE SIGNING THIS DOCUMENT
1. I UNDERSTAND VACCINATIONS MAY BE REQUIRED BY THE COLLEGE OR BY THE COUNTRY TO WHICH I AM TRAVELLING. IT IS MY
RESPONSIBILITY TO LEARN AS MUCH AS POSSIBLE ABOUT THE RISKS OF THE VENTURE, TO WEIGH THESE RISKS AGAINST THE ADVANTAGES,
AND TO DECIDE WHETHER OR NOT TO PARTICIPATE. I AGREE TO ATTEND A TRAVEL CLINIC PROVIDED BY THE BC MINISTRY OF HEALTH AND
CONSIDER ALL VACCINATIONS RECOMMENDED.
2. I UNDERSTAND THAT I AM RESPONSIBLE FOR ENSURING I HAVE APPROPRIATE TRAVEL AND MEDICAL INSURANCE FOR THE ENTIRE TIME I AM
AWAY FROM BRITISH COLUMBIA AND THAT I MUST PROVIDE EVIDENCE OF THIS TO THE OFFICE OF GLOBAL ENGAGEMENT.
3. I AGREE TO ABIDE BY THE RULES AND REGULATIONS OF NORTH ISLAND COLLEGE, THE OFFICE OF GLOBAL ENGAGEMENT, AND THE STUDY
ABROAD/FIELD SCHOOL PROGRAM, AS WELL AS ANY CHANGES THAT MAY BE MADE WHILE I AM A STUDENT AT THE COLLEGE.
4. I CERTIFY THAT ALL STATEMENTS MADE ON THIS APPLICATION FORM ARE TRUE AND CORRECT. I UNDERSTAND THAT MISREPRESENTATION OF
THIS INFORMATION IN ANY MATERIAL WAY MAY RESULT IN MY BEING WITHDRAWN FROM THE STUDY ABROAD/FIELD SCHOOL PROGRAM.
5. THE INFORMATION ON THIS FORM IS COLLECTED UNDER THE AUTHORITY OF THE COLLEGE AND INSTITUTE ACT. THE USE OF THIS
INFORMATION WILL BE IN COMPLIANCE WITH THE FREEDOM OF INFORMATION AND PROTECTION PRIVACY ACT. ANY QUESTIONS CONCERNING
THE COLLECTION AND USE OF THIS INFORMATION SHOULD BE DIRECTED TO THE OFFICE OF GLOBAL ENGAGEMENT.
