application for study abroad* - gallaudet university · study abroad/internship placement country:...

APPLICATION FOR

STUDY ABROAD*

*Note: The study abroad application applies to participants in the internship, exchange, and research programs.

Return all forms to: Gallaudet University • Office of Research

Return all forms to: Gallaudet University • Office of Research Support and International Affairs • Dawes House • Washington • DC • 20002-3695 • (202) 651-5051 • (202) 651-5746 FAX • [email protected] • www.gallaudet.edu/RSIA.html

RSIA Form I-0014 - Rev 201601271738 of 15

WELCOME!

Dear Gallaudet Study Abroad Applicant,

The experience of studying abroad for several months will be of tremendous value to you culturally, linguistically, personally,

intellectually, and spiritually. It will also enhance your employment opportunities in today’s competitive and interconnected

world.

As an international traveler, you will be a foreigner, and thus a minority—perhaps for the first time in your life. Occasions may

arise in which you will face positive or negative experiences simply from being a member of a minority. The more

knowledgeable you are about your host county before you arrive there will help prepare you in how to respond to a variety of

situations, therefore helping ensure that your experiences are enriching.

Studying abroad not only offers vast opportunities to learn, it allows you to make use of your previous experiences and

academic preparation. The more knowledge you have gained on a particular country's language and culture through formal

study or otherwise, the easier it will be to fit in and feel at ease in new surroundings. Books, newspapers, magazines, web

sites, television, and videos are all resources that can help prepare you for your journey, but the best way to get candid

information about your host country is to talk to people. Most people love to share their experiences and will be delighted to

talk with you. Students, faculty, and staff who have lived or worked in your host country, as well as nationals of that country,

are all excellent resources for information and advice.

Interacting with people from your host country will enable you to learn more about their culture, practice your language skills,

and make new friends. Some of your friends will be other Americans, of course, but be careful not to wrap yourself socially in

a cocoon. Interacting with natives is the best way to immerse yourself in a new culture. Many of your fellow study abroad

students will also be unfamiliar with your host country, giving you both something in common. This can form a bond of

friendship between you while you learn together the new customs and language you are exposed to. Above all, do not isolate

yourself at your residence or limit yourself to sightseeing; doing so will deny you one of the most enriching aspects of the

study abroad experience.

You may never again have the opportunity to live outside of the U.S. for an extended period of time. Whether you are

pushing your way through crowds at a large art exposition, or you are struggling to make conversation using your host

country’s language, remember that you are lucky to be experiencing something new and stimulating. Don’t dwell on any

missteps and frustrations you may encounter. These are normal. Rather, think of your experience as an adventure where

unknown rewards await you that you would never encounter if you had stayed at home. Cherish those days when you make

a new friend, you are fascinated by the rich history and culture of the city, or you find yourself gazing at magnificent

landscapes you never dreamed existed.

Indeed, you may be challenged about many of your values and beliefs. Foreigners may question you about aspects of your

life, or your country’s politics, questions will make you defend—or think twice about—what it is you stand for. Nonetheless,

you will return to the U.S. with a stronger sense of purpose, with a clearer idea of what it means to be a Deaf person or a

Deaf American abroad, and with new perspectives on yourself and the world.

(Note: Adapted from NAFSA: Association of International Educators Study Abroad Manual.)


RSIA Form I-0014 - Rev 201601271738 of 15

MISSION STATEMENTS

GALLAUDET UNIVERSITY Gallaudet University, federally chartered in 1864, is a bilingual, diverse, multicultural institution of higher education that

ensures the intellectual and professional advancement of deaf and hard of hearing individuals through American Sign

Language and English. Gallaudet prepares its graduates for career opportunities in a highly competitive, technological, and

rapidly changing world.

OFFICE OF RESEARCH SUPPORT AND INTERNATIONAL AFFAIRS

The Office of Research Support and International Affairs (RSIA) at Gallaudet University facilitates global education and

international opportunities that enrich the academic and cultural environment at Gallaudet and promotes crosspollination of

ideas.

BEFORE ACCEPTANCE

1. Be currently enrolled and in good standing at Gallaudet University.

2. Attend a study abroad session with an instructor or academic advisor or visit the Office of Research Support and

International Affairs (RSIA) in Dawes House.

3. Meet with your academic advisor to determine necessary coursework and/or graduation requirements.

4. Provide the Academic Recommendation Forms to two faculty or staff people who can recommend you.

5. If you are a United States citizen and do not currently have a passport, apply for a passport right away. An

application form can be obtained online at http://www.travel.state.gov/passport/passport_1738.html

6. Return completed application with your mandatory deposit (if required) and a recent passportsize photograph to

RSIA.

7. Ensure all required forms are completed and returned by the stated deadline. (Check the program flyer/poster, etc.,

for additional information.)

FORMS/DOCUMENTS REQUIRED

Biographical Information Form Emergency Contact Information Form

Passport/Citizenship Information Form Educational Information & Statement of Purpose Form

Health Statement Form Health Insurance Information Form

Health Provider’s Medical Statement Form Academic Recommendation Form

A recent passportsize photograph

Deadline: Check with your program

AFTER ACCEPTANCE

1. Complete and submit the Study/Global Internship Abroad Contract.

2. Complete and submit Liability Waiver Form (Appendix B in Emergency Action Protocol).

3. Application for scholarship (if required) will be forwarded to the appropriate office.

4. Contact RSIA about visa requirements (nonUS citizens).

5. Attend mandatory predeparture orientation with instructor, academic advisor, or RSIA representative.

Questions? Contact the Office of Research Support and International Affairs at 2026515815 or email us at

[email protected]

http://www.travel.state.gov/passport/passport_1738.html

mailto:[email protected]


RSIA Form I-0014 - Rev 201601271738 of 15

BIOGRAPHICAL INFORMATION

PLEASE PRINT

Last Name: First Name: MI:

Date of Birth:

Student ID#: SS#:

Class: Freshman Sophomore Junior Senior Graduate Cumulative GPA:

Major:

I will graduate (date):

Study Abroad/Internship Placement Country:

Semester and/or Year: Fall 20 Spring 20 Summer 20 Full Academic Year 20 / 20

Program: Study Abroad Program Global Internship Program Other

Are you a previous participant? No Yes If yes, Year/Month and Country:

CURRENT MAILING ADDRESS Address: _____________________________________________________________________________________________

City: State: Zip:

Telephone: Voice VP Fax:

Email:

PERMANENT/HOME ADDRESS Address: ______ ______________________________________________________________________________________________

City: _______________ ___ State: Zip:

Telephone: _____________ Voice VP Fax:

Email:


RSIA Form I-0014 - Rev 201601271738 of 15

PLEASE PRINT

EMERGENCY CONTACT

EMERGENCY CONTACT INFORMATION


Address: _____________________________________________________________________________________________

City: State: Zip:


Email: Pager:

ALTERNATE CONTACT IN CASE OF EMERGENCY (IF FIRST CONTACT IS NOT AVAILABLE)

Last Name: First Name MI:

Address:

_____________________________________________________________________________________________

City: State: Zip:


Email: Pager:

EMERGENCY MEDICAL AUTHORIZATION

In the event of a medical emergency, the University will make every effort to reach the person(s) designated as an

emergency contact before using the authorization below. In the event that we are unable to communicate with the emergency

contact person(s) immediately, your signature on this optional authorization may assist in obtaining necessary medical care.

Choose A or B:

A) To prevent dangerous delay in the event of an extreme emergency requiring hospitalization and/or surgery, I hereby

authorize the Crisis Management Team, or the appropriate authority of the Gallaudet University program, to secure whatever

treatment is deemed necessary for me, including the administration of an anesthetic and/or surgery.


Signature: Date:

B) I do not authorize Gallaudet University to secure medical treatment on my behalf.


Signature: Date:


RSIA Form I-0014 - Rev 201601271738 of 15

PASSPORT AND CITIZENSHIP INFORMATION

Attach a copy of the biographical data page of your passport to this form

PASSPORT INFORMATION

All students must complete this form. Your passport must be valid for the entire period (plus 180 days) of your study and

travel abroad. Otherwise, immigration officials will not allow you to leave the United States.

It is essential that you fill out this passport information page and provide a photocopy of your passport. This information page

and the copy of your passport will be provided to the Department of Public Safety (DPS) upon your departure from the U.S.

for your Study Abroad program. DPS is the emergency point of contact for the University.

Copy this form, and the information page of your passport, for your parents/guardians so they also will have a record of

your passport information. If your passport is lost or stolen, this information will make replacement much easier.

Print your full name as it appears on your passport.

Last Name: First Name: Middle Name:

Citizenship: PassportIssuing Country:

Passport #: Date Issued: Expiration Date:

Date of Birth: Place of Birth:

INTERNATIONAL STUDENTS ONLY

IMMIGRATION STATUS/VISA INFORMATION

Students who are traveling with other than a U.S. passport should inquire immediately about passport and visa

requirements at the appropriate consulate for their program. They should also inquire with U.S. immigration authorities

about the possible necessity of obtaining a new visa to reenter the U.S. (if their visa has expired or will expire) after the

completion of their program abroad.

Visa Type: I20/DS2019 Expiration Date: Visa Expiration Date:

RSIA CERTIFICATION

International students with either F1 or J1 visas must meet with Gallaudet’s Office of Research Support and International

Affairs (RSIA) to discuss the possible implications of study abroad for their immigration status. Have your RSIA advisor sign

below.

RSIA Advisor: Title:

Signature: Date: Email:

CERTIFICATION

I certify that I have met with the RSIA advisor to discuss my plans to study abroad. I understand the possible implications of

such study for my immigration status.

Student Signature: Date:


RSIA Form I-0014 - Rev 201601271738 of 15

EDUCATIONAL INFORMATION AND STATEMENT OF PURPOSE

EDUCATIONAL BACKGROUND Last Name: First Name: MI:

Current School:

School Address:

School Telephone: Email:

Expected Graduation Date: Major: GPA:

STATEMENT OF PURPOSE

In the space below, write a brief statement explaining your reasons for applying. Include your educational objectives, career

plans, and reasons for choosing to study or work abroad. The statement should be typewritten or printed neatly in black ink.

Attach an extra page, if necessary.

How did you hear about the program?


RSIA Form I-0014 - Rev 201601271738 of 15

HEALTH STATEMENT

To the applicant

Any international placement can be both physically and emotionally stressful. Please provide an honest evaluation of your

physical health by answering the following questions. If you answer YES to any of the questions, explain below or on a

separate sheet of paper, describing the details of the condition or treatment, including any medication taken.

HEALTH STATEMENT INFORMATION

Please explain any “yes” answer

1. Do you have any dietary restrictions or known food allergies? Yes No

If yes, explain:

2. Do you have any physical disabilities or impairments that might cause hardship as a result of change

in diet or strenuous travel, or that might otherwise affect participation in a study abroad program?

Yes No

3. Have you ever been diagnosed with any kind of learning disability? Yes No

4. Are you currently undergoing treatment for a medical condition? Yes No

5. Are you currently taking medication? Yes No

6. Are there any concerns relating to your health or family’s health? Yes No

7. Have you ever had any of the following:

a. A surgical operation (or been advised to have one) Yes No

b. T r e a t m e n t in a hospital or mental institution Yes No

c. A major illness requiring hospitalization Yes No

d. Allergies to medication Yes No

e. Other allergies (list names):

Yes No

f. Disorders not specified above, including eating disorders Yes No

8. Do you have any conditions that could affect your adjustment to a new culture or to the academic

program abroad? Yes No

9. Have you attached a copy of your health insurance card? Yes No


Applicant Signature: Date:


RSIA Form I-0014 - Rev 201601271738 of 15

HEALTH CARE PROVIDER’S MEDICAL STATEMENT

Please provide this form to your health care provider (Student Health Service or your family doctor).

Student’s Last Name: First Name: MI:

To the provider: In evaluating the applicant, please consider evidence of irritability, headaches, insomnia, depression,

allergies, asthma, and other disorders (such as diabetes). Attach an extra page, if necessary.

IMMUNIZATION RECORD:

MMR Immunization Dates

Or

Measles (Rubella):

Mumps:

Rubella Immunization Date

/ / : / /

/ / : / /

/ / : / /

/ / : / /

Result:

TD (Tetanus/Diphtheria) Booster:

Polio: IPV

Or

OPV:

/ / : / / : / /

/ / : / /

/ / : __/ / : / /

Hepatitis A:

Hepatitis B:

Varicella (Chicken Pox):

Tuberculosis Testing/Treatment

/ / : / / : / /

PPD Date / / Result in mm:

IfPositive,ChestXRayResult:

ALLERGIES:

MEDICATIONS TAKEN REGULARLY:

MEDICAL CONDITION:

I have examined the above named student and believe that this individual is physically and mentally qualified for placement

abroad. This individual is free from tuberculosis and presents no evidence of communicable disease, overfatigue, or any

other condition that would affect participation in a placement abroad program.

Name of provider:

Address:

Telephone: Fax: Email:

Provider’s signature: Date:


RSIA Form I-0014 - Rev 201601271738 of 15

HEALTH INSURANCE INFORMATION

Attach a copy of your insurance card/coverage.

District of Colombia and Gallaudet University policy require all enrolled students to carry adequate medical insurance

coverage. Students without adequate medical insurance are automatically charged a medical insurance fee by the Peter J.

Fine Student Health Service (SHS), which provides both regular medical coverage and coverage for Gallaudet sponsored

events overseas. If your private policy does not meet SHS guidelines, you must purchase the University's health insurance

plan. Provide your medical insurance information below and attach a copy of your insurance card. If you have private

insurance, have SHS certify this form.

Note: Medicare does not provide overseas medical coverage. You are advised to purchase separate medical coverage for

your trip abroad.

INSURANCE INFORMATION


Name of Insurance Company:

Address of Insurance Company: _____________________________________________________________________________________________ _____________________________________________________________________________________________

Phone Number of Insurance Company:

Group Policy Number: ID#

Name of Employer:

Name of Primary Insured: _DOB

Your Relationship to Primary Insured:

I affirm that the statements above are true and correct to the best of my knowledge: Last Name: First Name: MI:

Signature: Date:


RSIA Form I-0014 - Rev 201601271738 of 15

ACADEMIC RECOMMENDATION

TO THE APPLICANT:

This form is to be completed by a person other than a friend or family member who is familiar with your academic work.

Complete the top portion of this form and provide your reference with a stamped envelope addressed to: Office of Research

Support & International Affairs, Gallaudet University, 800 Florida Avenue, NE, Washington, D.C. 200023695, USA

Under the provisions of the Family Educational Rights and Privacy Act,

I retain my rights of access to information contained in this recommendation.

I waive my rights of access to information contained in this recommendation.


Signature of applicant: Date:

TO THE REFERENCE PROVIDER:

The applicant named above is applying for the study/work abroad program sponsored by Gallaudet University. Students are

selected on the basis of academic ability and personal maturity. Please provide your frank opinion of the applicant’s maturity

and qualifications. Please submit your response as soon as possible; a late response may impair/delay the applicant’s

admission to the program. Note that the applicant has been given the option of waiving or retaining the right of access to this

recommendation.

1. For how long and in what capacity have you known the applicant?

2. Please assess the quality and level of the applicant’s academic work, describing strengths and weakness.

3. How would you rate the applicant’s ability to adjust to new or changing situations or environments?

4. Please describe how the applicant relates to others, including teachers and peers.

5. Please make any additional comments about the applicant’s qualifications for participation in this program.

6. General Comments:

7. I strongly recommend this applicant for the study abroad program.

I recommend this applicant, but have reservations as noted above

I do not recommend this applicant for the study abroad program.

Name of Reference: Position/Title:

Address:

Telephone: Email:

Signature: Date: May we contact you if we have any

questions about your recommendation? Yes No

STUDY ABROAD/GLOBAL INTERNSHIP CONTRACT

CONDITIONS FOR ENROLLMENT

I (print full name) am a student enrolled in a Gallaudet

Universitydeveloped study abroad program or a Gallaudet Universityapproved study abroad program.

I understand that I must deliver to the Office of Research Support and International Affairs (RSIA) a signed copy

of the Study Abroad Contract prior to the start of a study abroad program and before leaving the Gallaudet

campus.

A. Behavioral Responsibility Initials

I am aware of the expected behavioral responsibility while participating in this program.

As a guest in a foreign country, there are certain behaviors which are considered unacceptable and

could lead to possible disruption of the program.

I hereby assure the University that I shall conduct myself in an appropriate manner which does not

infringe upon the customs and mores of the country in which the program is being conducted, nor upon

the rights and safety of myself and of other participants in the program.

Behavioral responsibilities shall be applicable during the course of the program, both when in the

company of other program participants and when I am apart from other program participants.

In addition, I must adhere to all policies outlined in the Gallaudet Student Handbook. Inappropriate

behavior is cause for dismissal from the program without refund.

Illegal Drugs:

I understand that the use or possession of illegal drugs during the program, or being knowingly present in

instances of use or possession of illegal drugs during the program, is cause for immediate dismissal from

the program without refund.

Involuntary withdrawal:

I acknowledge that return passage and all other expenses incurred by my involuntary withdrawal

from the program shall be my sole and exclusive financial responsibility.

B. Academic Responsibility Class Attendance:

I am required to attend all regularly scheduled classes, field trips, and other activities.

Course Registration:

To receive credit for study abroad programs not developed by Gallaudet, I will assume responsibility for

registering myself at the host institution, and working with the Gallaudet Registrar’s Office to assure that

credit is accepted at Gallaudet.

C. Financial Responsibility Application Fee:

I must pay any applicable fees required by Gallaudet or other sponsoring institutions and

organizations.

Cancellation Policy:

If I decide to withdraw from a Gallaudetdeveloped program within two months prior to the start of the

program, I agree to pay a fee as specified in the program information.

Deposit Policy:

Upon acceptance to a Gallaudetdeveloped study abroad program, I am required to submit to the Office of

Research Support and International Affairs (RSIA) within 14 days a nonrefundable deposit as specified in

the program information. (Check or money order payable to Gallaudet University).

I must be registered for the Gallaudetdeveloped program before the start of the program and pay the bill

by the dates specified on the bill from Student Accounts. Failure to do so will preclude my participation in

the program.

Program Fees:

I am responsible for the applicable program fee, which may include tuition, room and board, and other

expenses as outlined in the program information.

D. Medical Responsibility: I acknowledge that there are certain risks inherent in international travel and that Gallaudet

University cannot assume responsibility for the provision of medical services to its students.

I am expected to have consulted a medical doctor with regards to my medical issues or needs. Further, I

am aware that the University cannot be responsible for attending to any of my medical needs.

I am aware that should I be required to be hospitalized while in a foreign country or in the United States

during the program, the University cannot and does not assume legal responsibility for payment of such

costs.

I hereby assure Gallaudet University that I have assumed all risk and responsibility and I have adequate

insurance to meet any and all needs for payment of hospital costs during the course of the study abroad

program.

E. Health Insurance

I understand that I am required to maintain sufficient health, accident, disability, and hospitalization

insurance while participating in this program.

The Office of Research Support and International Affairs requires participants to purchase an

International Student Identity Card (ISIC) as a minimum coverage.

Gallaudet University shall not assume responsibility for student medical expenses. Participants in

programs through sponsoring institutions and organizations may be required to enroll in a specific

insurance plan designated by the institution or organization.

F. Consent to Emergency Medical Treatment: I acknowledge that on rare occasions an emergency may develop which necessitates the

administration of medical care, hospitalization, or surgery.

Therefore, in the event of injury or illness to myself necessitating emergency medical care, I hereby

authorize Gallaudet University and its authorized representative(s) or agent(s) in charge of the study abroad

program to secure any necessary treatment deemed appropriate, including the administration of anesthetics

and surgery.

G. Students with Disabilities:

I acknowledge that the absence of laws in some countries mandating equal access for individuals

with disabilities affects the ability to provide accommodations in certain locations.

Disclosure of the disability to the Office of Students with Disabilities and RSIA will ensure that every

effort is made to provide access to certain locations and for requesting accommodations for the

disability.

H. Release from Liability:

I agree that Gallaudet University, its officers, employees, agents, and representatives

shall not be legally responsible for any claims, demands, liabilities, costs, or causes of

action based upon or arising from any illness or injury (including death) or property loss

or damage, deviation, delay, or curtailment, however caused, which I may suffer in

connection with enrollment or participation in any study abroad program.

I. Indemnification:

I shall indemnify and hold harmless Gallaudet University, its officers, employees, agents,

and representatives from any and all claims, demands, liabilities, costs, and causes of

action, and all incidental expenses (including reasonable attorney’s fees) based upon or

arising from any illness or injury (including death), property loss or damage, or other

liability caused by or resulting from my act or omission during enrollment in the study

abroad program.

J. Program cancellation and withdrawal:

I understand that Gallaudet University reserves the right to cancel any program without notice, in

which event all moneys paid will be refunded in full. Gallaudet University also reserves the right to

decline any application.

K. Permission Form:

To ensure that all preparations are successfully completed before the time of departure, a

Permission to Study Abroad Form will be given to me to fill out and return to RSIA.

The form will be in effect when signed by both the Director of RSIA and the Provost. The

undersigned agrees to complete and comply with the terms of this form.

L. Orientation:

I agree to attend a predeparture orientation program that will be conducted during the semester

immediately prior to my participation in a Gallaudetdeveloped study abroad program.

M. Living Arrangements: I acknowledge that housing accommodations vary from one location to another. Because of the

nature of the actual arrangements with institutions and organizations abroad, I may not be free to

make my own private arrangements.

I agree to accept the housing provided in the host country, whether it is in a university dormitory, an

apartment, or with a family. Every effort will be made to accommodate my preference, but this can

be done only within the limits of the available housing.

N. Travel:

Study abroad for credit programs at Gallaudet are not travel tours. While travel during free time can

be quite educational in itself, the University does not grant academic credit for travel.

The study abroad for credit programs, whether in classroom, internship, or service learning settings,

are strictly academic in nature, and students in study abroad programs must expect to invest at least

the same amount of time and effort as would be required at home for academic experiences at the

same level.

Travel or weekends and holidays must not conflict with the regular class or program schedule;

students are responsible for making travel plans that will permit them to attend all regularly

scheduled classes, activities, and field trips.

O. Signatures Student:

Faculty/StaffCoordinator:

Director of RSIA:

Director of Risk Management:

application for study abroad* - gallaudet university · study abroad/internship placement country:...

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