study abroad application

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					                                                                                        Mt. San Antonio College
                                                                                        Study Abroad Program
                                                                                               26A-1630
                                                                                         909.594.5611 x4177

                                               Student Application for: _________________________________________
                                                                                                    Program name
            Application procedure:
                o Submit your completed application to the Study Abroad Office
                o Pay for deposit at Bursar’s Office and attach copy of your receipt to this application
                o Attach a photocopy of the picture page of your passport

Part A: financial aid status                          (SKIP THIS SECTION IF YOU ARE NOT GOING TO APPLY FOR
                                                       FINANCIAL AID TO PARTICIPATE IN THIS PROGRAM)
Approximate Date you filed the FAFSA ________________
              Have you received your Student Aid Report (SAR) back from the processor?       YES      NO
              Have you attended a Loan Counselling Session (Required by Federal Regulation)? YES     NO
              Are you currently receiving a Pell Grant this semester?                        YES     NO
              Do you have any student loans outstanding at the present time?                 YES     NO

                       How many college credits (units) have you completed to date? _________________



Part B: personal data
Name………………………………………………………………………….…………………..………                                                    Male _____          Female ____ Age……………………….

Date of birth (d/m/y)….…/………/..……..Student I.D. #…………………………………………GPA………..…… Major………………………………

Citizenship*………………….………………..Passport #*………………………………..………..Date & place of issue*…………………………………..…….….

Place of Birth*.…………………………………………….…..

Permanent contact address (number/street)………………………………………………….…………………………………………………………………………….…..
   (city)…………………………………..…………(state)…………………………………(zip)………………………….…….…..(phone)…………………………………..…..…

    (email) ……………………………………………………..……………………..

Emergency contact details (name & relationship)…………………………………….………………………………………………………………………………..……..
   (Phone)……..………………..…………………………………                                              (Email)……………………………………………………………………………………...



Part C: housing information
Please complete this questionnaire carefully. Your housing assignment may be based on the information that you provide. All requests are taken into consideration.

Are you able to climb stairs?         YES       NO                                   Do you require a single room (subject to availability)?          YES        NO


Roommate preference (if known) (1)…………………………………………………... (2)……………………………….……………….………
(Please note that both parties must make the same request)

Is there a student you do NOT want to live with? ……………………………………………………………..

Do you smoke?                         YES        NO                                  Do you object to a roommate who smokes?                      YES       NO

What time do you get up in the morning?……………………………………..Go to bed?……………………………………………………….

Do you consider yourself to be a quiet person? YES                  NO               Where do you prefer to study? ROOM                  LIBRARY        OTHER

How many hours of television do you normally watch a day?……………………………………………………………………………….……

What type of music do you prefer?………………………………………..Do you normally listen to music in your room?                                                   YES       NO
Part D: medical self-assessment
The purpose of this form is to help staff abroad to be of maximum assistance to you should the need arise during your study abroad
experience. Mild physical or psychological disorders can become serious under the stresses of studying abroad. It is important that the
program be made aware of any medical or emotional problems, past or current, which might affect you in a foreign study context. The
information provided will remain confidential and will be shared with program staff, faculty, or appropriate professionals only if pertinent to
your own well-being. The information you provide will not affect your acceptance to the program. It is strongly recommended
that you fill out this portion of the application, but it is not mandatory.
A separate sheet may be used if necessary.

medical history (Please circle )
1.   Are you generally in good physical condition? (if no, please explain)                              YES     NO

2.   Have you ever been treated or are currently being treated for any psychological
     or emotional problems? (if yes, please explain)                                                    YES     NO

3.   Do you have any allergies (if yes, please explain)                                                  YES    NO

4.   Are you taking any medication? (if yes, please explain)                                             YES    NO

5.   Have you had any major injuries, diseases or ailments in the past
     five years? (if yes, please explain)                                                                YES    NO

6.   Are you a vegetarian or are you on a restricted diet? (if yes, please explain)                     YES     NO

7.   Is there any additional information (concerning medical conditions or physical
     disabilities) that would be helpful for the program to be aware of during your
     study abroad experience? (if yes, please explain)                                                   YES    NO

8.   Are you receiving any special medical treatment? (if yes, please explain)                           YES    NO

I certify that all responses on this Medical Self-assessment form are true and accurate, and I will notify the Program Director of any
relevant changes in my health that occur prior to the start of the program.

Signature of participant………………………………………………………………….Date………………………………

In the event of an emergency, staff abroad will make every effort to reach the individual designated as an emergency contact before using
the authorization below. However, in the case of an emergency, your signature on this optional authorization may assist in obtaining
necessary medical care:
     A) To prevent dangerous delay in the event of an extreme emergency requiring hospitalization and/or surgery, I hereby authorize
        the designated official of Mt. San Antonio College, or Pleasant Holidays to secure whatever treatment is deemed medically
        necessary, including the administration of an anaesthetic and/or surgery.

Signature……………………………………………………………………………..Date……………………………….

     B) I choose not to authorize the designated official to secure medical treatment on my behalf.

Signature……………………………………………………………………………..Date……………………………….

Release agreement
I hereby release Mt San Antonio College from responsibility for any loss or damage arising from any cause whatsoever, and shall not hold
my school responsible for any sickness, injury or death, or for any loss or damage arising from any errors or omissions contained in the
program material. In addition, Mt. San Antonio College shall have the right, without liability or cost, to cancel any program or make
alteration in program components in the event that the aforementioned is rendered impossible or inadvisable for any cause that is beyond
the college’s control.

Mt. San Antonio College is not responsible for my well-being when I am absent from official program activities, during my free time or
during periods of independent travel. I release my school from all claims arising out of acts of omission by persons or entities outside of
its control (without limitations), including airlines, surface transportation organizations and other suppliers of program services. Mt. San
Antonio College is not responsible for any costs arising from the loss or theft of any of my personal property at any time.

I agree to abide by all program rules as specified by Mt. San Antonio College and the organizations with which they cooperate including
those written in program materials provided to participants in both the United States and overseas.


Signature of participant………………………………………………………………….Date……………………….………

				
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