visit us application form 2010 2011

8/8/2019 Visit Us Application Form 2010 2011

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International Education Office, UCC of 8

Please complete ALL sections of form. Please complete form in BLOCK CAPITAL letters. Return completed form anddocumentation to: International Education Office, University College Cork, Cork, Ireland. Website: www.ucc.ie/internationa

Office use only Student Number

Last Name (As on Birth Certificate)

Other Name(s) (As on Birth Certificate)

Date of Birth Year: Month: Day:

Country of Birth Male: Female:

Permanent Home Address

City/ Town State

Country Postcode

Telephone No. Cell PhoneNo.

Email Address

Please print email address in CAPITAL LETTERS. It is very important to provide an accurate email address as it will be used forcorrespondence during the application process.

Next of Kin Name

Next of Kin Contact TelephoneNumber

Next of Kin

Email

Please print email address in CAPITAL LETTERS.

Visiting Student Application Form 2010-2011

1 Personal Details

2 Next of Kin Contact Details

http://www.ucc.ie/international

http://www.ucc.ie/international




1

2

3

4

5

Student Module Preference:

It is recommended that students take modules to the value of 60 UCC credits for the academic year and modules valued at 30UCC credits for the semester. To view the range of modules on offer to Visiting Students please see the Book of Modules forVisiting Students at the following link:

http://www.ucc.ie/study/international/visiting/modules/book-modules

Note: Visiting Students may ONLY choose modules from The Book of Modules for Visiting Students

Code Module Title

1

2

3

4

5

6

7

8

9

10

Please Note:

Even though every effort will be made to ensure that students will be admitted to their preferred module choices, theInternational Education Office CANNOT GUARANTEE admission to any particular module.

6 Courses for w hich you are currently enrolled at your home college/university

7 Module Selection

Please list below your modules choices , in order of preference




To be completed by the Home Institutional Official. Please use BLOCK CAPITALS or type.

Student Name

Social Security No.

ProgrammeCountry

Study PeriodPlease tick box

Early Start Autumn only Spring only Full Academic Year 20___

Please have Section 2 of this form completed by the Study Abroad Advisor or appropriate person at your Home Institution whoapproves study abroad. It is important that you understand your Home Institution’s policy for accepting credits earned for study

abroad before you leave.

TO THE HOME INSITITION OFFICAL:

The student named above is applying for a study abroad programme at University College Cork. If accepted, the student isexpected to enrol in a full academic programme. We would appreciate your evaluation of the student.

Is the student in good academic standing? Yes No

If No, please explain:

Has this student been subject to disciplinary action? Yes No

If Yes, please explain:

Will credits earned by the student on their study abroad programme be applied toward completion of a degree awarded by your institution? Please tick box

Yes, provided the student passes each course with a grade of _____ or better

Yes, on the following condition:

No

Study Abroad Approval Form for Visiting Students

1 Student Details

2 Approval by Home Institution Official




Have you discussed your institution’s poli cy for accepting credit with theabove-named student?

Yes No

Has the student show n satisfactory adjustment to college life in general? Yes No


Do you recommend this student? Yes No

Yes, with reservations, please explain:

Additional Comments:

Name

Position

Institution

Address

Telephone

Fax

Email

Signature of Home Institution Official Date

3 Home Institution Official’s Details




This form is to be completed by the applicant

Last Name:

First Name(s):

The purpose of this form is to help UCC to be of maximum assistance to you should the need arise during your study abroadexperience. Mild physical or psychological disorders can become serious under the stresses of life while studying abroad. It isimportant that UCC be made aware of any medical or emotional issues, past or current, which might affect you in a foreignstudy context. Please note that UCC may not be able to accommodate all individual needs or circumstances.

1 Are you generally in good physical condition? Yes No


2 Have you ever been treated or are you currently being treated for any

psychological or emotional issues?

Yes No

If Yes, please explain and indicate any medication which has been prescribed:

3 Do you have any allergies to drugs, insects, plants or food? Yes No


4 Do you carry any indication of your allergies which would assist UCC ormedical staff in the event of illness?

Yes No

If yes, please explain:

Health & Safety Information Questionnaire

Medical History




5 Are you currently taking any medications? Yes No


6 Have you had any major injuries, surgeries, diseases or ailments in thepast five years?

Yes No


7 Is there any additional information (concerning medical conditions ormental, learning or physical disabilities) that would require action inthe event of a medical emergency or be helpful for the programme tobe aware of during your study abroad experience?

Yes No


I certify that all responses made on this Health Information Questionnaire are true and accurate and I will notifyUCC hereafter of any relevant changes in my health that occur prior to the start of the programme. I understandthat, in the event of an emergency abroad, UCC reserves the right to notify my parent(s) or guardian(s).

The information provided will remain confidential and will be shared with programme staff, academic staff orappropriate professionals only if pertinent to your own well being.

Applicant’ s Signature Date

Declaration




1 Complete Visiting Student Application Form in Full

2 Complete Study Approval Form for Visiting Students

3 Complete Health and Safety Information Questionnaire

4 Please ensure that the following documentation is received by the International Education Office:

1. Full Academic Transcript(s) from Home Institution2. Academic Reference from your academic advisor or a professor at your Home Institution

5 Please return the completed Application Form to the following address:

International Education Office,University College Cork, ‘Roseleigh’, Western Road,Cork,Ireland

Early Start Semester, Autumn Semester and Full Year Applications 31 May 2010

Spring Semester Applications 29 October 2010

I acknowledge that the particulars given on this form are in all respects true.

Applicant’ s Signature Date

Instructions on Completion of Application Form

Application Closing Dates

Declaration

visit us application form 2010 2011

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