TS 074 application France, Amiens Alcott.doc

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					                                               University of Colorado at Denver and Health Sciences Center
                                                                    International Education, Study Abroad
                                                Mailing Address: Campus Box 185, P.O. Box 173364, Denver, Colorado, 80217-3364
                                                                                  Physical Location: 1380 Lawrence St., Suite 932
                                                  Phone: (303) 315-2230; Fax: (303) 315-2246 E-mail: study.abroad@cudenver.edu
                                                                                         Internet: http://international.cudenver.edu


                                                                                                       To be completed by OIE:
                                                                                                       _______ IEO fee posted
SUMMER 2007:
                                                                                                       _______ ISIC card created
TRAVEL STUDY APPLICATION                                                                               _______ database complete
                                                                                                       _______ acceptance sent
CLAS: TRAVEL STUDY: AMIENS, FRANCE                                                                     _______ confirmation received
                                                                                                       _______ registration complete


Please complete the steps below and retain this checklist for your records. Please note that incomplete applications
will not be considered. Please feel free to call us with any questions you may have.

                                          Final application deadline: March 1, 2007

Acceptance letters will be sent via email during the week of March 8, 2007 – we require your confirmation of
participation, so please watch your email carefully. The program requires a minimum of 14 confirmed
participants. Do not purchase air tickets until you receive final program confirmation from the Office of
International Education based on 10 confirmed participants. (If the program is not confirmed your $400
deposit will be refunded.)

APPLICATION CHECKLIST

Please submit the following together to UCDHSC Office of International Education - Incomplete applications will
not be accepted. Please use the mailing address for regular mail and the physical address for Express/FedEx mailings.

        Program application – including:
        - program and contact information page                                                            PHOTO
        - payment information and refund policy signature                                               Passport size
        - assumption of risk and health statement signature
        - recommendation form
        - Travel Study registration form
        Transcript (unofficial is fine)
        One photo Printed photo must be attached. Needed for the International Student Identity Card,
        (approximately 1 inch x 1 inch) front view. See www.myisic.com for more information on this important ID
        card which includes a catastrophic travel insurance, as well as discounts around the world.
Passport Information
Passport information can be found at http://travel.state.gov/passport/passport_1738.html. Apply for a passport several
months before your departure. If you are in need of a visa, allow for additional time as the consulate will need your
passport in order to issue the visa.

Visa Information
It is your responsibility to find out if you need a visa for your host country, and if so, to obtain it. You can visit
www.embassy.org for the contact information for foreign consulates. International students should meet with an International
Student and Scholar Services advisor for important information on immigration and travel issues.



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                                                                                                                              Page 1 of 5
     University of Colorado at Denver and Health Sciences Center                                           Office of International Education, Study Abroad

                            APPLICATION FOR TRAVEL STUDY PROGRAMS, SUMMER 2007


           UCDHSC, Office of International Education, Study Abroad  Campus Box 185  P.O. Box 173364  Denver, CO  80217-3364




I.          PROGRAM AND CONTACT INFORMATION

Program Name and Location: Travel Study: Amiens, France

Participant Name _______________________________________________________________________________
                                   LAST NAME                                  FIRST NAME                  MIDDLE


Student Identification Number _______________________________________

Date of birth _____/____/______                             Gender     Male      Female           Marital status     Single      Married
                       MO    DAY     YEAR


Country of citizenship _______________________ If non U.S Citizen, Immigration status__________________________

E-mail: ___________________________________________________
(Please inform OIE of all changes to your contact information, particularly your email address.)

Current address

______________________________________________________________________________________________________
            STREET                             APT/BOX NO                                  CITY                     STATE                ZIP


Current telephone: Cell (____) ____ - _______                        Home (____) ____ - _______           Other (____) ____ - _______

Permanent address

______________________________________________________________________________________________________
            STREET                             APT/BOX NO                                  CITY                     STATE                ZIP


Permanent Telephone (____) ____ - _______

Send all mailings to:

     Current address, valid from _____/_____ to _____/_____                      Permanent address, valid from _____/_____ to _____/_____


College/university now attending _______________________________ Major ______________ Minor _______________

Current standing                     FR        SO       JR      SR      Graduate

Degree program ________________________________________ Cumulative GPA ______________________________


Emergency contact ___________________________________ Relationship _____________________

       Emergency email address _____________________________________________________________

       Emergency phone: Home (_______) _______ - _________ Other (_______) _______ - __________

       Emergency street address _____________________________________________________________




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  University of Colorado at Denver and Health Sciences Center                                 Office of International Education, Study Abroad


II.        PAYMENT INFORMATION FOR OIE FEE AND LATE FEES

By submitting this application, you understand that a non-refundable International Education Opportunities fee of $400 will be
charged to your student account. This fee is immediately due. Please submit your payment directly to the bursar’s office.


III.       REFUND POLICY FOR ALL STUDY ABROAD PROGRAM CHARGES

The non-refundable International Education Opportunities fee of $400 applies to all travel study and education abroad programs.

For UCDHSC Travel Study programs:

       If you are not accepted into a Travel Study program, your $400 fee will be returned to you.

       Any Travel Study applications received after the deadline will be accepted if space is available, with an additional $50 late
       fee.

       Students canceling 60 or more days before the start of the program will receive a refund of the program cost, less the $400 fee
       (and late fee, if applicable), and less any expenditures for the program which have already been made.

       Students canceling 30 days prior to the start of the program will receive a refund of 50% of the program cost, less the $400 fee
       (and late fee, if applicable), and less any expenditures for the program which have already been made.

       Students canceling after 30 days before the start of the program will receive no refund.

In the case of substantiated unforeseen or unanticipated medical reasons, and subject to review and consent of the OIE Director,
exceptions may be made to the above Refund Policy. Notification of withdrawal must be submitted in writing to Stephanie
Ronollo, Study Abroad Coordinator, Stephanie.Ronollo@cudenver.edu .



I have read and fully understand the Payment Information and Refund Policy:


Name/signature/date _________________________________________________________________________________




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  University of Colorado at Denver and Health Sciences Center                            Office of International Education, Study Abroad

IV.      ASSUMPTION OF RISK AND HEALTH STATEMENT

Please list information concerning your healthcare provider, and read and sign the Release. The following information will remain
confidential and will be used in order to assist you should you have a medical emergency.

Medical health insurance company ________________________________ Policy number __________________________

The overall state of my health is         Excellent       Good         Fair

I have    Chronic medical conditions          Allergies         None

Please list medical condition(s) and/or allergies:
______________________________________________________________________________________________________

I regularly take following medications:
______________________________________________________________________________________________________

Release from Responsibility, Assumption of Risk, and Waiver

Please read this information carefully before signing. Its effect is to release the University and/or
Department for any liability resulting from your participation in the program you have applied for and
waives all claims for damages or losses against the University and/or Department.

In consideration of the University of Colorado at Denver and Health Sciences Center making arrangements
for and permitting me to participate in a UCDHSC study abroad program, I exercise my own free choice to
participate voluntarily in program activities and fully assume all associated risk and promise to take due
care during such participation. I hereby release, discharge, indemnify, and hold harmless the University of
Colorado at Denver and Health Sciences Center, and its members, officers, agents, employees, and any
other persons or entities acting on its behalf, and the successors and assignees for any and all of the
aforementioned persons and entities, against all claims, demands and causes of action whatsoever, either in
law or equity arising from my participation in the UCDHSC study abroad program. I understand that I am
solely responsible for any costs arising out of any bodily injury or property damage sustained through my
participation in normal or unusual acts associated with the UCDHSC study abroad program. I believe I am
in good health, and affirm that my participation in the UCDHSC study abroad program will in no way
aggravate any condition(s) present, whether known or unknown to me. If I become injured or aware of any
conditions that may jeopardize my participation, I will notify OIE within five (5) business days of such
occurrence. If in doubt, I will seek further medical advice.

I have had sufficient time to review and seek explanation of the provisions contained above, have carefully
read them, understand them fully, and agree to be bound by them. After careful deliberation, I voluntarily
give my consent and agree to the above Release, Assumption of Risk, and Waiver. By my signature below I
attest that I not aware of any medical condition or limitation that would preclude my participation in a study
abroad program and I further attest that I have not been advised by a health-care provider or medical expert
that participation in a overseas program might be injurious to my health or otherwise contra-indicated.


I have read and fully understand the Assumption of Risk and Health Statement:

Name/signature/date

_________________________________________________________________________________



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                                                                              TRAVEL STUDY REGISTRATION FORM


Name ___________________________________________________________________________Student Number ________________________Date of birth _____/_____/_____
           LAST NAME                                    FIRST NAME                        MIDDLE                                                                                        MO        DAY       YEAR


Permanent address
_________________________________________________________________________________________________________________________________________________
                                             STREET                  APT/BOX NO                       CITY                                         STATE                   ZIP                    COUNTRY


Telephone - Home ___________________________                                      Work ___________________________                      E-mail _________________________________________________

Ethnic Origin (Optional)                                                                  Citizenship                                                         Gender

   American Indian or Alaska Native             Asian or Pacific Islander                     U.S. Citizen                                                        Female         Male
   Black, not of Hispanic origin                White, not of Hispanic origin                 Non-U.S. Citizen Visa Type__________________
   Hispanic                                     Other                                         Country of Citizenship_______________________

ALL APPLICANTS PLEASE ANSWER QUESTIONS BELOW
  Do you have a high school diploma? Yes________ No ________  Do you have a college degree? Yes ______ No ______
  If yes, please indicate name of College/University _____________________________________________________Degree ___________________ Date ___________________
  Have you ever enrolled for credit courses at any campus of the University of Colorado (Denver, Boulder, Health Sciences, Colorado Springs or Extended Studies)? Yes ____ No ____
  If yes, at which campus? _________________________________________
  If you are a U.S. male born after December 31, 1959, the following selective service question must be answered to comply with Colorado state law: Are you registered with the U.S.
   Selective Service? Yes ______ No ______  Have you ever been convicted of a felony? Yes ______ No ______

    If you are not a CU student, please indicate where you would like your transcript to be sent at the completion of your program
_______________________________________________

Term(s) abroad          FALL       WINTER        SPRING          SUMMER      Year(s) 2007

                                                                                                                      SECTION        CREDIT
                   TITLE OF COURSE & DEPARTMENT #                                        COURSE NUMBER                                                FOR TRAVEL STUDY, FACULTY LEADER’S NAME
                                                                                                                      NUMBER         HOURS

                                                                                               FR 2995
                    TRAVEL STUDY: AMIENS, FRANCE                                                                                         6
                                                                                               FR 3995




I certify to the best of my knowledge that the information furnished on this application/registration is true and complete without evasion or misrepresentation. I understand that if found to be otherwise, it is
sufficient cause for rejection or dismissal. I understand that admission to the University of Colorado at Denver and Health Sciences Center as a non-degree student does not guarantee eligibility for regular degree
status. I understand that I am responsible for these program fees, and that I will notify OIE if I feel my bill is incorrect. I understand that program fees posted on brochures are estimates, and that the program fee
may increase or decrease.

APPLICANT’S SIGNATURE __________________________________________________________________________________________ DATE ____________________________________________




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