Study Abroad Application:
Step #1
Program Selection:
Which program are you applying for? NOTE: Programs require additional application materials and an interview.
_______________________________________________________ ________ ________________
First Name MI Last Gender Date of Birth
*Must be age 18 on or before the date of departure.
____________________________________ _________________________________ ____________
Country of Citizenship E-mail Address Telephone #
__________________________________________________________________________________________
Mailing Address City State Zip Code
______________________________________ __________________________________
Faculty Reference (Who is filling out your form?) Passport # (If you do not yet have a passport write “Pending”)
Are you currently a student If Yes, what is your student ID #? _____-______-_____
at Shoreline Community College? If No, were you enrolled at SCC in the past?
Field of Study:_____________________________ Cumulative GPA __________
(Minimum GPA required for some programs)
The following information is used for accommodation placements and statistical information only. SCC does not discriminate with
regard to program participation on any basis. SCC will make every effort to place you according to your requests, but cannot guarantee
doing so.
Please list any physical restrictions: _________________________________________________________
Please list any dietary restrictions: __________________________________________________________
Please list any medications you will be taking: _________________________________________________
Please list any known allergies (including pets): ________________________________________________
Do you smoke?
Do you request any academic or physical accommodations?
Anything else you would like us to know: ______________________________________________________
Yes No
Yes No
Educational intent at SCC :
Yes No
Yes No
Print and turn in completed form to the International Programs Office PUB 9303.
