Registration/Billing Authorization and Scholarship Application FormWinter 2016 Course Abroad to Thailand

INSTRUCTIONS – Please Read Carefully:This form must be completed electronically, printed and submitted to the Center for International Education (Barnard Hall, Room 123) on or before close of business (4:30 p.m.) on the registration deadline (stated below). Registration forms received after the registration deadline will be processed on a space-available basis. Submission of this form authorizes CCSU to secure travel arrangements on your behalf, and to charge you in accordance with the Course Abroad Cancellation Policy stated below.  Note also that you must enroll in the course(s) connected to this program separately via normal course registration methods and that normal CCSU course registration and course cancellation policies apply.

PERSONAL INFORMATION

Last Name (exactly as it appears on your passport): Click here to enter text.First Name (exactly as it appears on your passport): Click here to enter text.8-digit CCSU ID Number: Click here to enter text. CCSU e-mail address: Click here to enter text.Cell phone number: Click here to enter text. Home phone number: Click here to enter text.Birth date (MM/DD/Year): Click here to enter text. Gender: (click box) Male ☐ Female ☐

PASSPORT INFORMATION ☐Check here if you have never had a U.S. passport or if your passport has expired*.

Country of Issue: Click here to enter text. Date of Issue: Click here to enter text.Passport Number: Click here to enter text. Expiration Date: Click here to enter text.

* IMPORTANT NOTE: If you do not currently have a valid passport or your passport will expire within six months of the return date of this program, you should apply for a new passport immediately. Failure to obtain or renew your passport does not alter or exempt you from the Course Abroad Cancellation Policy. The Center for International Education will need a copy of the information page of your passport ASAP. You may be subject to additional airline ticketing fees if the name on this registration form does not exactly match how your name appears on your passport.

STATEMENT OF UNDERSTANDING and BILLING AUTHORIZATION

I understand the following statements, as they pertain to my participation in this Course Abroad program, and I understand that I will be held financially responsible in accordance with the cancellation schedule below.

Registration Deadline and Billing Information• The registration deadline for this program is 4:30 p.m. on Thursday, October 1, 2015;• The CIE Travel Program fee (payable directly to the Bursar, online via my Pipeline account) is due December 1, 2015.• Payment may not be required immediately but must be completed by the listed payment deadline. If payment assistance is necessary a

payment plans are available through the Bursar’s Office (www.bursar.ccsu.edu).

Program Costs• The cost of the travel program, EXCLUSIVE OF COURSE TUITION AND FEES, is $3,095 per person. This fee covers round-trip

economy class airfare, all accommodations, ground transportation and entrance fees to required sites of interest, and some meals. • A CIE Travel Program Fee will be billed to my University account upon receipt of this form; this fee is not an “all-inclusive” price (for

what is included in the cost, see the 2016 Course Abroad Program Catalog and the CIE website for this program.)

Cancellation Policy - Read carefully! By submitting this form, you are incurring a financial responsibility!Dropping a course associated with this program does not constitute proper withdrawal from the Course Abroad program. The dates in this policy hold true no matter when you register for the program. Students who must cancel their participation in a Course Abroad program must do so in writing to Lisa Marie Bigelow in the Center for International Education. To ensure proper delivery, students must email notice of cancellation to Bigelow@ccsu.edu from their CCSU e-mail account. CIE Travel Program fees will be reversed/refunded according to the following schedule:

Cancellations received prior to 4:30 p.m. on Friday, October 2, 2015 You are responsible for a $100 Cancellation Fee

Cancellations received after 4:30 p.m. on October 2 and before 4:30 p.m. on Friday, October 9, 2015 You are responsible for 25% of the CIE Travel Program Fee

Cancellations received after 4:30 p.m. on October 9 and before 4:30 p.m.on Friday, October 16, 2015 You are responsible for 50% of the CIE Travel Program Fee

Cancellations received after 4:30 p.m. on October 16 and before 4:30 p.m.on Friday, October 23, 2015 You are responsible for 75% of the CIE Travel Program Fee

Page | 1

Cancellations received after 4:30 p.m. on October 23, 2015 You are responsible for 100% of the CIE Travel Program Fee

ACADEMIC INFORMATION 

Eligibility Criteria

You must hold Good Academic Standing Status (2.00 or above for undergraduate students and 3.00 for graduate students) in order to register for this program;

It is your responsibility to ensure that you meet all course prerequisites.

Academic Major: Click here to enter text. Minor/Concentration: Click here to enter text.Earned Credit Hours: Click here to enter text. Grade Point Average: Click here to enter text.Enrollment Status: Full-time Matriculated ☐ Part-time Matriculated ☐ Non-Matriculated ☐Home Campus: CCSU ☐ ECSU ☐ SCSU ☐ WCSU ☐ Other: Click here to enter text.

Course EnrollmentPlease identify which course(s) you will be registering for as part of this Course Abroad program. NOTE: You must register separately for the course via the normal course registration process. A separate charge will be placed on your bill for course fees. Dropping the course associated with this Course Abroad Program does not constitute a withdrawal from this Program or alter or exempt you from the Course Abroad Cancellation Policy stated on page 3.

☐ GEOG 290 ☐ GEOG 459 ☐ GEOG 559

Non-Credit ParticipationParticipation in this program on a non-credit basis is subject to the review and approval of the faculty member(s) leading this program. Non-credit participation is available on a space-available basis only; priority will be given to students enrolling in this course for academic credit. A $300 non-credit surcharge applies to anyone approved to participate on a non-credit basis.

If you wish to participate on a non-credit basis, you must consult with the faculty member(s leading this program and obtain their signature(s) here:

Faculty Approval to Participate on a Non-Credit Basis:

This student has my permission to participate in this program on a non-credit basis.

________________________________ ___________________________ ________________________________Faculty Signature Printed Name Date

Special Needs or Disabilities

Any student wishing to assert a disability that requires accommodation must submit supporting documentation from the appropriate professional(s) to the Office for Student Disability Services. Are you registered with Disability Services? ☐Yes ☐ No

SCHOLARSHIP APPLICATION ☐Check here if you are submitting a Scholarship Essay with this Form.

The Center for International Education, in conjunction with the CCSU Foundation, Inc, is offering a limited number of scholarships for participants in this Course Abroad program. To be considered eligible for CIE scholarship assistance, applicants must: (1) submit this registration form to the Center for International Education on or before the program registration deadline, (2) be matriculated at CCSU, (3) register for a course associated with the program, (4) not receive tuition remission/waivers, and (5) submit a 750-1000 word Scholarship Essay with this Registration Form. Scholarships will be awarded on a competitive basis and preference will be given to students whose GPA exceeds 2.50. Registration for this Course Abroad program does not guarantee award of a scholarship and that should be taken into consideration when planning how you will finance your participation in this program.

Select one of the following three questions and attach a 750-1000 word essay.

Page | 2

1. How will participation in this program benefits you academically?2. How will your future employers benefit from your study abroad experience?3. Why have you chosen to study abroad on this particular program?4. What do you expect to learn from this experience?

Student’s Name: Click here to enter text. CCSU ID Number: Click here to enter text.

PROGRAM BUDGET:

To ensure that you have thoroughly considered the financial obligations, please complete the worksheet below:

Travel Program Fee: $3,095.00

Course Tuition: $Click here to enter text.Personal/Incidentals: $Click here to enter text.Total Program Costs: $ Click here to enter text.

Please indicate how you plan to fund your Course Abroad experience (amounts can be approximate but should equal or exceed the Total above).

☐ Personal Savings $ Click here to enter text.☐ Student Loan(s) $ Click here to enter text.☐ Credit Card $ Click here to enter text.☐ Family Contribution $ Click here to enter text.☐ Other_________________ $ Click here to enter text.

TOTAL $Click here to enter text. This total should equal or exceed the Total Cost of Attendance above. If it does not, please think carefully before submitting this form to the Center for International Education because by submitting this form, you are incurring a financial obligation in accordance with the Course Abroad Cancellation Policy stated on page 3.

RELEASE AND APPLICATION SIGNATURE:

I have read this Registration/Billing Authorization and Scholarship Application Form carefully, understand its terms, and acknowledge that I am subject to the following Course Abroad Cancellation Policy:

Dropping a course associated with this program does not constitute proper withdrawal from the Course Abroad program.Students who must cancel their participation in a Course Abroad program must do so in writing to Lisa Marie Bigelow in the Center for International Education. To ensure proper delivery, students must email notice of cancellation to Bigelow@ccsu.edu from their CCSU e-mail account. CIE Travel Program fees will be reversed/refunded according to the following schedule:

Cancellations received prior to 4:30 p.m. on Friday, October 2, 2015 You are responsible for a $100 Cancellation Fee

Cancellations received after 4:30 p.m. on October 2 and before 4:30 p.m. on Friday, October 9, 2015 You are responsible for 25% of the CIE Travel Program Fee

Cancellations received after 4:30 p.m. on October 9 and before 4:30 p.m.on Friday, October 16, 2015 You are responsible for 50% of the CIE Travel Program Fee

Cancellations received after 4:30 p.m. on October 16 and before 4:30 p.m.on Friday, October 23, 2015 You are responsible for 75% of the CIE Travel Program Fee

Cancellations received after 4:30 p.m. on October 23, 2015 You are responsible for 100% of the CIE Travel Program Fee

I acknowledge that I am accepting the charges generated by this registration in a CCSU Course Abroad Program. I agree that I am legally obligated to pay these charges in accordance with University payment deadlines and/or formal withdrawal policies. I understand that a hold will be placed on my account until any past due balance is paid in full.  The hold will prevent registration for future terms and the release of transcripts.  If I fail to make agreed upon payments, I will be responsible for both the amount due and costs of collection.  

I hereby authorize officials at any educational institution that I have attended to release my university records (including, but not limited to, records maintained by the Office of Student Conduct, the Registrar, the Department of Residence Life, and/or the Office of the Vice President for Student Affairs) to the CCSU Center for International Education. I fully understand that my University records may be a factor in evaluating my application. I further acknowledge that the information provided on this application is true and accurate to the best of my knowledge. I fully understand that providing false information during the application process may be grounds for rejecting my application or grounds for dismissal from the program. I agree to be subject to the Course Abroad policies of the Center for International Education, including those presented here, on the Center for International Education’s website, and in all relevant pre-departure and orientation materials.

Page | 3

 _____________________________________________________________ ____________________________________ Student’s Signature Date

Page | 4

Center for International EducationCentral Connecticut State University

Statement of Responsibility, Release, Indemnification and Authorization to Participate In a Course Abroad Program

 I, (insert name) Click here to enter text., agree to participate in the course abroad to Thailand sponsored by Central Connecticut State University (CCSU) from January 4-17, 2016. I understand and hereby acknowledge that my participation in the Program is wholly voluntary. In consideration of being allowed to participate in the program, I hereby agree as follows: I have been advised and am aware of the inherent and/or latent danger (including but not limited to: risk of serious injury, the hazards of travel, accident, or illness, or acts of God) of participating in a program requiring international travel. I am aware and have been advised to have a medical examination prior to participating in this activity to insure that I am in good physical health. Further, I hereby represent and warrant that I am and will be covered throughout the Program by a policy of comprehensive health and accident insurance which provides coverage for injuries or illness I may sustain or experience overseas. By my signature below, I certify that my health insurance policy will adequately cover me while outside the United States; and, I absolve CCSU and the host institution of all responsibility and liability, except for that which arises out of the negligent acts or omissions of the University or its employees, for any injuries (including death), illness, claims, damages, charges, bills and/or expenses I may incur while I am abroad. I agree to report to the University any physical or mental condition I have which may require special medical attention or accommodation during the program at least thirty (30) days prior to departure. I am also aware and have been advised that I will be enrolled by CCSU in a supplemental insurance policy which provides for unlimited coverage of international medical evacuation and repatriation of remains. I understand that this is a university sponsored program, and that standards of Central Connecticut State University must be observed. I accept that the University reserves the right to decline to accept or retain me in the Program at any time should my actions or general behavior impede the operation of the Program or the rights or welfare of any person. Similarly, if my conduct violates any CCSU policy or procedure, I understand that I may be required to leave the Program at the sole discretion of the employees, agents, or representatives of CCSU, and I may be referred to the appropriate CCSU officials for further disciplinary or other actions. In such an event, I am responsible for reimbursing CCSU for the cost of my participation in the Program. CCSU reserves the right, in its sole discretion, to cancel the Program or any aspect thereof prior to departure; and, in its sole discretion to cancel the Program or any aspect thereof after departure, may require that all participants return to the United States, if CCSU determines or believes that any person is or will be in danger if the Program or any aspect thereof is continued.  I understand that CCSU reserves the right to make changes to the Program itinerary at any time and for any reason, with or without notice, and CCSU shall not be liable for any loss whatsoever to me by reason of any such cancellation or change. CCSU is not responsible for penalties assessed by air carriers that may result due to operational and/or itinerary changes, regardless of whether CCSU makes a flight arrangement. Any additional expense resulting from the above will be paid by me. CCSU reserves the right to substitute hotels or accommodations or housing of a similar category at any time. Specific room and housing assignments are within the sole discretion of CCSU. I understand and acknowledge that the University assumes no responsibility or liability, except for that which arises out of the negligent acts or omissions of the University and its employees, in whole or in part, for any delays, delayed or changed departure or arrival times, fare changes, dishonored hotel, airline or vehicle rental reservations, missed carrier connections, sickness, disease, injuries (including death), losses, weather, strikes, acts of God, circumstances beyond the control of the University, force majeure, war, quarantine, civil unrest, public health risks, criminal activity, terrorism, accident, damage to property, bankruptcies of airlines or other service providers, inconveniences, cessation of operations, mechanical defects, failure or negligence of any nature howsoever caused in connection with any accommodations, restaurant, transportation, or other services or for any substitutions of hotels or of common carriers beyond the University’s control, with or without notice, or for any additional expense occasioned by any of the foregoing. If due to weather, flight schedules, or other uncontrollable factors I am required to spend additional nights in travel status, the University will not be responsible for my hotel, transfers, meal costs, or other expenses. My baggage and personal property are transported at my risk entirely.

Page | 5

Student’s Name: Click here to enter text. CCSU ID Number: Click here to enter text.

I am aware of and understand the risks and dangers of travel to, in, and around the country/countries to be visited, including but not limited to the dangers to my own health and personal safety posed by the use of public transportation, and by civil unrest, political instability, terrorism, crime, violence, and disease in the country/countries to be visited. I hereby assume, knowingly and voluntarily, each of these risks and all of the other risks that could arise out of or occur during my travels to, from, in or around the country/countries to be visited. I understand that I bear full legal and financial responsibility for all indebtedness or other legal obligation incurred by me while a Program participant. In the event of sickness or injury, I hereby authorize the Program Director of the host institution, or his or her designee, to secure whatever medical treatment is deemed necessary, including admission to a hospital, the administration of anesthetics, the transfusion of blood, and surgery. I agree that this Waiver, Release and Indemnification Agreement is to be construed under the laws of the State of Connecticut, U.S.A.; and that if any portion hereof is held invalid, the balance hereof shall, notwithstanding, continue in full legal force and effect. In signing this document I hereby acknowledge that I have read this entire document, that I understand its terms, that I will abide by each of the terms, that by signing it I am giving up substantial legal rights I might otherwise have, and that I have signed it knowingly and voluntarily. STOP!!! THE FOLLOWING SECTION MUST BE COMPLETED IN THE PRESENCE OF A NOTARY PUBLIC:

____________________________________________ __________________________________________________Participant’s Signature Date

CCSU ID Number: ____________________________ Date of Birth: ______________________________________  Address; ________________________________________________________________________________________

(Number and Street name) (City/Town) (State) (Zip Code) TO BE COMPLETED BY NOTARY PUBLIC:

NOTARIZATION: ________________________________________ (student’s name) personally appeared before me, and by me known, and swore or affirmed that she/he freely and without reservation signed this release form. ____________________________________________ __________________________________________________Notarized by Date

 

Health Insurance & Emergency Contact InformationRequired of All Participants in a CCSU Course Abroad Program

Information you provide on this form will not disqualify you from participating in this program. It is critically important that you be honest and include all conditions and medications since the faculty director(s) will relay this information to foreign healthcare providers should you become incapacitated while traveling with them.

Page | 6

Student’s Name: Click here to enter text. CCSU ID Number: Click here to enter text.

 I agree to inform the Center for International Education of any health or medical conditions or needs that may affect my participation in this program. I agree subsequently to inform the Center for International Education of any health or medical condition or need that should develop after this document is submitted and prior to the date of departure or during the program. I understand that I must make sufficient provisions before departure for continuation of medical treatments, such as prescriptions or special diet. 1. In case of emergency, whom in the United States should we notify? (Please be sure to tell them you will be traveling abroad!)

Primary Emergency Contact: Secondary Emergency Contact:Name: Click here to enter text. Name: Click here to enter text.Relationship to you: Click here to enter text. Relationship to you: Click here to enter text.Home Telephone: Click here to enter text. Home Telephone: Click here to enter text.Work Telephone: Click here to enter text. Work Telephone: Click here to enter text.Cell phone: Click here to enter text. Cell phone: Click here to enter text.

  2.  List all past and current medical issues and surgeries (other than brief illness or minor injuries).

Check None, if applicable. ☐ None

Click here to enter text.

3. List all mental health conditions for which you have been treated by a mental health or medical professional in the last five years. Check None, if applicable. ☐ None

Click here to enter text.

4.  List all medications you currently take (both prescribed and over-the-counter). Check None, if applicable. ☐ None

Condition Medication(s) taken for this conditionClick here to enter text. Click here to enter text.Click here to enter text. Click here to enter text.Click here to enter text. Click here to enter text.

5.  List all allergies (e.g., medication, environmental, food, etc.) Check None, if applicable. ☐ None

Condition Medication(s) taken for this conditionClick here to enter text. Click here to enter text.Click here to enter text. Click here to enter text.Click here to enter text. Click here to enter text.

6. Do you have Health Insurance? ☐ Yes ☐ No

Insurance Company: Policy Number/Group Plan Number Telephone Number:Click here to enter text. Click here to enter text. Click here to enter text.

___________________________________ ____________________________________ Signature Date

Page | 7