MBA-PM Chile Program Application January 9 - 16, 2010 by by654321


									                           MBA-PM Chile Program Application
                                         January 9 - 16, 2010
     (Depart the US on January 8 /Depart Chile on January 16th/Arrive back in the US on January 17th)
All student participants must complete & submit all of the following forms:
   ( ) This application form
   ( ) Signed Conditions of Participation
   ( ) Signed Medical Self-Assessment Form
   ( ) Proof of Medical Insurance Form
   ( ) IPO Disciplinary Regulations Form
   ( ) Copy of your passport photo page – Copy must be clear and legible

Completed application (all materials listed above) is due by 5:00pm on Friday, August 14, 2009.

Program Fee: $2050 -- Includes: Shared lodging; Coordination of professional visits and speakers; Classroom
space; Airport transfers in Santiago (available at a proscribed time window); A bi-lingual group tour manager
available 24/7; A orientation to Santiago upon arrival; Bus transportation to all professional visits; Day excursion
into the Andes Mountains; Excursion to Pacific Coastline (including visit to vineyard); Some meals (including all
breakfasts); Supplemental health insurance and assistance for international travel;

Optional Single Room Supplement Fee: $585 -- By paying this fee students, will have their own room for all
nights of the program.

        I request a single room for this program and agree to pay the additional $585 room supplement.

Personal Information:
 Last name                                                     First name                           Middle initial

 Current address (Address where travel agency should send program materials in December.)

 City                                                          State                         Zip Code

 Home Phone                                   Other phone (optional)              Check one:
 Email Address: (Email will be the primary communication for this program so please provide an email
 address you will regularly check)

 Date of Birth (Month/Day/Year)               Student ID Number:

 Indicate if you have any diet restrictions. This information will be used for planning any meals provided
 under this program. Check all relevant boxes:
   I am vegetarian.
   Other dietary restriction: _____________________________________________________________
   Other dietary restriction: _____________________________________________________________
 May we release your name and contact information to other participants in this program and to the
 companies that will be hosting our group in Chile?   Yes          No

    Companies typically request that we provide the name of all individuals who will be visiting with our group.
 Travel Information:
Passport Information:
           Country of Issuance: _____________________________________________

           Passport Nuimber:     _____________________________________________

           Check this box if you currently do not have passport:

If you do not yet have a passport, you MUST apply for one immediately. (Application processing
typically takes 4 to 6 weeks.) The following website directs you on how to apply for a US passport:

           Check this box if your current passport will expire on or before July 8, 2010:

A standard recommendation is to renew your passport if you plan to travel outside the US within six
months of your passport’s expiration date.

 International Experience (optional)
Have you traveled outside of the US?     □ Yes □ No      If yes, please state where you have traveled:

 Emergency Contact Information:
Name of contact person: (Must not be on trip with you)               Relationship to you:


City                                  State                          Zip code

Daytime phone                                            Evening phone

Email                                                                             Fax
                                    Program Fees, Tuition and Penalties

The Student Program Fees will be charged in installments to your U-Bill. If you withdraw from the program you
will be assessed a cancellation fees as set out below:

Program Fee Payment Schedule (U-Bill Charges)                                Date                        Amount
                                                                            Sept 2009                     $1025
                                                                            Oct 2009                      $1025*

* Students who have selected the Single-Room Supplement will also be charged $585 to your Dec U-Bill

Withdrawal Dates                                                                                  Withdrawal Fee
Before Oct 10, 2009                                                                                       $ 0
Oct 10 – Nov 8, 2009                                                                                      $ 350
Nov 9 – Nov 28, 2009                                                                                      $ 700
Nov 29 – Dec 19, 2009                                                                                     $1050
Dec 20, 2009 or After                                                                                     $2050*

* Students who withdraw on or after December 20 are subject to a withdrawal penalty amounting up to the entire
program fee.

Tuition Payment Schedule (U-Bill)                                             Date                  Amount
                                                                             Nov 2009               $ 1,800

                                           Application procedure:
                         After making copies for your reference, this application is due
                                           By August 14, 2009 to:

                                    You can submit application by mail or email
                           By Mail                                              By Email
           Institute for International Business             Students can scan completed documents and email
                    Attn: Ann Knudson                               them to
        108 Pappajohn Business Building, W308
                  The University of Iowa
                   Iowa City, IA 52242

____________________________________________                                            ________________________
Signature                                                                               Date

                 Contact Ann Knudson, Assistant Director, Institute for International Business
                         Phone: 319-335-1379 / Email:

For SOM Office Use Only
Date Received           Time Received             Received by ( Initials)
University of Iowa                                               Name ____________________________________________

Medical Self-Assessment                                          Program:    Chile Program January 2010
                                                                 Country: Chile Date: 1/9/10-1/16/10

Because studying abroad can be both physically and emotionally demanding, we ask that you provide a candid
evaluation of your health. A certain amount of stress due to culture shock or living conditions and facilities can be
expected. In some cases, this may aggravate disabilities or illness which you have under control at home, or trigger onset
of a previously undiagnosed condition.

This information will not be used in determining your admission to this program, but to guide us in making appropriate
arrangements, as needed, for you. The information will be forwarded to the program director or coordinator abroad.
Additionally, we hope completion of the form will create an awareness on your part of any health issues that you should
take into consideration before going abroad.

Instructions: Please read each question below and answer either YES or NO by checking the appropriate box.
If you answer YES for any question, please provide additional information in the space provided.

Do you have any pre-existing medical conditions?                                         YES             NO
If YES, please elaborate:

Do you currently receive any treatments or medications on a regular basis?               YES             NO
If YES, please elaborate:

Do you have any dietary restrictions?                                                    YES             NO
If YES, please elaborate:

Do you have any known allergies to medication, plants, food, animals, insect             YES             NO
stings, etc.?
If YES, please elaborate:

Do you have any physical limitations or disabilities?                                    YES             NO
If YES, please elaborate:

Have you ever had a major surgical operation or been advised to have one?                YES             NO
If YES, please elaborate:
Have you ever had a major illness or injury?                                      YES            NO
If YES, please elaborate:

Have you ever sought counseling or treatment for any psychological, mental,       YES            NO
emotional or nervous disorder (including eating disorders or depression)?
If YES, please elaborate:

Are there any other concerns regarding your health, family history or other       YES            NO
matters that you would like to discuss with a Study Abroad Advisor before
your program begins?
If YES, please elaborate:

By signing below, I certify that the above information is true to the best of my knowledge. I also acknowledge
the following:

I, and my parents or guardians, agree to release and hold harmless the University of Iowa and their employees
and agents from any claims arising out of the provision of medical care while abroad.

I understand that this form will be released to the faculty director of my study abroad program and other
program staff as needed.

If my parents or guardians have not signed this form, I represent and certify that I am not a minor.

__________________________________________________________                 ________________________________
Signature of applicant                                                       Date

Name of applicant (printed)

__________________________________________________________                 ________________________________
Signature of parent or guardian (required for minors only)                     Date
                  Study Abroad Conditions of Participation
                    As a participant in a University of Iowa-sponsored study abroad program,
                                    I acknowledge and agree to the following:

        I. Health & Accident Insurance                • I acknowledge the risks associated with studying and
                                                        traveling abroad, and I authorize the University of Iowa,
      Traveling and living abroad involves some         its authorized representative(s) or the program coordinator
            personal risk. While serious medical        at the host institution, to secure any medical treatment
    emergencies are rare, you must consider the         determined to be necessary under the circumstances.
 possibility and make appropriate provisions for
   it. Health care services vary by country, and      • I acknowledge that such treatment shall be solely at my
  health insurance policies vary considerably in        expense.
     their coverage. Make sure that your health       • I confirm that a physician has approved of my
insurance policy is adequate for the country you        participation in this program, or that I agree to accept the
     will be living in! (Information about health       risk of my participation without such approval.
         insurance policies for students traveling
                       overseas is available in the   • I confirm that I have health and accident insurance
                         Office for Study Abroad.)      coverage for the duration of my stay abroad (including
                                                        travel to and from my destination), and that it is my
                                                        responsibility to insure the adequacy of the coverage.

                       II. Personal Conduct           • I will strive to understand and respect the cultural
                                                        differences that I encounter.
   Within our own cultural context, we generally
            know what conduct is expected of us.      • I will observe the laws of the country in which I will be
    Travelers in foreign cultures, however, often       residing and all academic and disciplinary regulations in
          find themselves in situations where the       effect at the host institution.
        appropriate behavior is not immediately       • As a degree candidate at the University of Iowa, I will
                obvious to them. The term “Ugly         also continue to adhere to the University’s Code of
    American” was coined long ago to describe           Student Life.
     one possible, and all too frequent, reaction
    to encountering cultural differences—riding
    roughshod over them. It is the University of
        Iowa’s expectation that your conduct be
      appropriate to the culture and country you
                                      are visiting.

                    III. Academic Conduct             • I will maintain a full course load while abroad, and take
                                                        full responsibility for my performance in those classes.
   Studying abroad is in most cases an unusually
        fruitful academic endeavor. While some        • For students conducting independent research for credit:
programs operate according to the U.S. model of         I take full responsibility to conduct the research agreed
     higher education, others require students to       upon in advance, and to produce the final product (e.g.
  adapt to a foreign educational system. Roles,         paper) required for my work to be evaluated and credit
         expectations and responsibilities can be       granted.
                              markedly different.

                 IV. Financial Obligations            • I am aware of the costs associated with this program, and
                                                        I agree to pay the required fees according to the
                                                        program’s fee schedule. (Students who receive financial
                                                        aid may be able to make arrangements with the Office of
                                                        Student Financial Aid for the temporary deferral of a
                                                        portion of their payment.)
                                                      • I acknowledge and accept the academic and financial
                                                        consequences of withdrawing voluntarily from the
                                                        program and/or returning home prior to the conclusion of
                                                        the program.
V. Agreement
    & Release   WHEREAS, (Indicate Full Name) __________________________________ ,
                hereinafter referred to as Student, is about to take a travel and study

                program described as the Chile Program, January 9 - 16, 2010; and,
                WHEREAS, it is acknowledged that said travel and study program involves
                some risk to person and property, including but not limited to the risk of injury
                due to accident and disease; and
                WHEREAS, it is acknowledged that said travel and study program may be the
                occasion of medical emergency necessitating the administration of medical
                treatment including hospitalization or surgery;
                NOW, THEREFORE, in consideration of said student being permitted to
                participate in said travel and study program, I do hereby, for myself, my heirs,
                administrators, and executors, and the undersigned as parent, parents, or
                guardian of said Student, do for ourselves and for and on behalf of said Student,
                all acknowledge and assume the risk of such travel and study program, and do
                hereby release and forever discharge the State of Iowa, State Board of Regents,
                and the State University of Iowa, (all entities hereinafter referred to as IOWA),
                and all of their officers, faculty, employees, volunteers, and agents whether
                accompanying said program or otherwise, from any and all claims, demands,
                actions, or causes of action, on account of any injury to me or my property, on
                account of my death, or on account of damages suffered by me for whatever
                reasons, which may occur from any cause, including negligence, or in
                connection with said travel and study program or any continuances thereof; and
                we do hereby expressly covenant and agree to refrain from bringing suit or
                proceedings at law or in equity or otherwise as provided by law, against any of
                said bodies or persons on account of any and all such claims, demands, actions,
                or causes of action. I voluntarily assume these risks. I have read and understand
                the program description. This document is executed with full knowledge of its

                If my parents or guardian have not signed this form, I represent and certify that
                I am not a minor.

                ______________________________________________                 _______________
                Signature of Applicant                                        Date
                     Statement of Medical Insurance Coverage

                                        Office for Study Abroad
                                        The University of Iowa
              Please return this completed form with the rest of your acceptance materials.

                                                             Please print legibly

Program abroad:                Chile Program, January 2010

Term abroad:                   January 9 - 16, 2010

Please check the box that indicates your actual health insurance coverage, and then complete the
information regarding your insurance below:

          My current health insurance plan covers treatment received while studying abroad.

          I have purchased a supplemental policy for students studying abroad.

          Name of insurance company:
          (or study abroad program, if health insurance is provided)

          Policy Number:

          Telephone number:

By this statement I acknowledge that I am aware of the University of Iowa requirement to have
medical/health coverage while studying abroad. I understand that study abroad students have additional
and somewhat different insurance needs than domestic students. The Office for Study Abroad has
provided me with information regarding supplemental international insurance. I hereby certify that I have
read the information and will be covered by one or more of the following insurance policies for the
duration of my study abroad program.

Signed:                                                                         Date:
                                                              L: OfSA/acceptance packet/generic/OfSA insurance form.doc
                  Program Academic and Disciplinary Regulations
                 Tippie School of Management International Studies

As a student of the Tippie School of Management (Tippie) International Program Option (IPO), I
hereby agree to abide by the following rules and policies set forth by Tippie in consideration of fellow
students, faculty, administration, and myself. I understand that failure to abide by these rules and
policies set forth by Tippie will lead to disciplinary action, and that such disciplinary action may include
immediate dismissal from the IPO program.

   1. Professional behavior is expected in all class and corporate activities. Participants who are
      judged to be intoxicated or under the influence of drugs before, during or after Tippie
      sponsored events may not be allowed to attend said events and/or allowed on Tippie
      sponsored transportation in the interest of the safety, health and welfare of fellow participants.
   2. Cooperation with any staff member’s reasonable request in the interest of participant’s safety,
      health and welfare is expected of all participants and their guests. Participants are expected to
      resolve disputes or conflicts in a cooperative manner. Fights, under any and all circumstances,
      will not be tolerated. Participants are encouraged to seek staff assistance to mediate disputes
      or to reduce the noise when reasonable requests are ignored.
   3. Conduct which is disruptive to the program or offensive to the host culture, or which endangers
      students or others, sexual harassment, racial or ethnic harassment, will not be tolerated.
      Conduct such as, but not limited to, abuse of alcohol, intentional and deliberate antagonistic
      behavior, disruptive noise, and abusive language toward fellow participants, program faculty
      and staff, or citizens of the host country will not be tolerated. Anyone who directs any
      deliberate and/or intimidating gestures toward another person or purposely humiliates, makes
      degrading comments, or removes personal computer files or material of any other student from
      any of the computers will be subject to disciplinary action.


   1. Participation in all class, academic and corporate activities is expected for all enrolled students.
      Attendance at all classes is mandatory. The following policy will be strictly enforced:
              • 1st Absence – loss of a letter grade
              • 2nd Absence – dismissal from the program.

       Two unexcused absences will lead to program dismissal. Participants are not allowed to take
       exams early, depart early from the Tippie program or miss class.

   2. Tippie considers all instances of academic fraud, such as but not limited to plagiarism,
      cheating and forgery, as serious academic misconduct and a major violation of the Tippie
      Honor Code.
Program Academic and Disciplinary regulations
I understand and I agree to abide by the Behavioral and Academic Policies and any other regulations
set forth by Tippie. My failure to follow these regulations and policies will result in disciplinary actions,
which may include my immediate dismissal from the program.

I understand that the Tippie Academic and Disciplinary Regulations do not follow a progressive
discipline framework. This means that I am not guaranteed a first warning before any disciplinary
action is taken.

I agree that Tippie has the right to enforce these standards of conduct in its sole judgment and that it
may impose sanctions, up to and including expulsion from the program, for violating these standards
or for any behavior detrimental to or incompatible with the interest, harmony and welfare of the
University of Iowa, the program or other participants. I recognize that due to the circumstances of
foreign study programs, procedures for notice, hearing and appeal applicable to student disciplinary
proceedings at the University of Iowa may not apply. If I am expelled, I consent to being sent home at
my own expense.

I waive and release all claims against Tippie, its officers, employees and agents that may arise at a
time when I am not under the direct supervision of Tippie or that are caused by my failure to remain
under such supervision or to comply with Tippie regulations, policies and/or instructions.

Student’s Printed Name______________________________________

Student Signature__________________________________________


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