INDEPENDENT STUDY ABROAD APPPLICATION CHECKLIST
IMPORTANT: Please be aware that transcripts may take 10 -15 weeks to arrive to SFA, make sure this will not
affect your graduation plans.
Part I - Before applying to your Study Abroad Program, submit to OIP the following documents:
□
Course Approval Form (CAF): All students who study abroad on a year, semester, or non-SFA summer program must
complete a Course Approval Form before departure. The Course Approval Form lists all the courses you are planning to
enroll in while abroad and it lists the SFA equivalents for these courses. This important piece of paperwork ensures that
your off-campus study plans are academically sound and that you will receive SFA credit for the work that you complete
while you are overseas!
IMPORTANT: When applying to your program, please indicate that the transcript should be sent to:
SFA Study Abroad Coordinator, P.O. Box 6152, SFA Station, Nacogdoches, TX-75962 – USA
Part II - Submit copy of your program application.
Part III - Once you have been accepted into the program:
$50 non-refundable SFA Study Abroad Application Fee Receipt: Fill out the payment slip included in the package, take it to
the SFA Business Office, Austin Building, 2nd floor and make your payment at the cashiers.
□
Proof of Health Insurance: Students must have, BY TIME OF DEPARTURE, adequate health insurance coverage for
studying outside the U.S., including repatriation of remains and emergency medical evacuation coverage
□
Study Abroad Concurrent Enrollment Agreement (If Applicable): This form enables you to apply for financial aid toward
your study abroad program if using a third party provider or ISEP Direct.
□
Scholarship Application with unofficial SFA transcript attached
□
Copy of your Passport
□
Flight Itinerary
Office of International Studies and Programs – Study Abroad Application
PO Box 6152, SFA – Nacogdoches, Texas 75962-6152
936-468-2961/6604/6631
INDEPENDENT STUDY ABROAD APPLICATION
Program term you are applying for:
Fall
Spring
Program Dates:
Summer
Your picture
Academic Year
Program Location:
Provider:
Provider Contact:
Personal Information
Full Name (as it appears on your passport):
□ Male □ Female
Student ID Number:
E-mail:
_______
Age: ____
Citizenship:
Date of Birth:
Place of Birth:
Predominant Ethnic Group (Optional)
___Asian/Pacific Islander ____Black
___White ____Hispanic ___Multiracial
__ American Indian
Local Address:
Cell Phone:
Permanent Address:
Phone:
Passport Number:
Exp.
List any medical problems, concerns or important medications needed while abroad:
Emergency Contact Information
Name:
Relationship:
Work/Cell Phone:
Name:
Relationship:
Work/Cell Phone:
Academic Information
Classification: □ Freshman
□ Sophomore □ Junior □ Senior
Major:
Cumulative GPA:
Minor:
Expected date of graduation:
Will you apply for Financial Aid? □ Yes □ No
Scholarships?
Your Academic Advisor:
Agreement
Office of International Studies and Programs – Study Abroad Application
PO Box 6152, SFA – Nacogdoches, Texas 75962-6152
936-468-2961/6604/6631
_______
I certify that all statements made on this study abroad application in its entirety are true and accurate.
I agree to be subject to the academic and financial policies of the SFA Office of International Programs (OIP)
in conjunction with the general policies of Stephen F. Austin State University.
I am in good academic standing with Stephen F. Austin State University.
I understand that transcripts may take 10-15 weeks to arrive to SFA and this may affect my graduation date if I’m
studying abroad during my last semester at SFA.
I agree to keep OIP informed about changes in the courses I’m taking while abroad.
I give permission to the OIP to obtain copies of all my university records.
During my participation in a study abroad program, I designate the OIP to be my campus representative.
I further direct the OIP to act in my behalf and release the stated information to any and all agencies,
business, or individuals that I direct in later correspondence. I understand that if I request official
documents while I am on a study abroad program, I will reimburse the OIP for any and all costs of said copies.
Applicant’s Signature
Print Applicant’s Name
Student ID number
Date
I verify that the student named above is not on academic probation and is in good standing with the
.(Department name).
Signature of Academic Advisor
Print Name
Office of International Studies and Programs – Study Abroad Application
PO Box 6152, SFA – Nacogdoches, Texas 75962-6152
936-468-2961/6604/6631
Date
AUTHORIZATION TO DISCLOSE CONFIDENTIAL STUDENT
AND MEDICAL INFORMATION
I, __________________________________________________ (ID# _________________________), hereby authorize the disclosure of protected student
and health information from Stephen F. Austin State University, Nacogdoches, Texas to the following person(s)
_____________________________ ________________________________________ (Relationship ___________________________________), who may be
contacted at ______________________________________________________________________ (Address/Phone) for the purpose of notification,
consultation, and other uses as may be necessary to effectively manage its international program and respond to the numerous
situations
which
could
arise
from
my
matriculation
in
the
following
international
program:
_______________________________________________________.
Description of protected student and health information to be disclosed:
Transcripts; grades; available test scores; disciplinary records; student activity records; any other student record regardless of where it
is maintained, some of which may be considered confidential under the Family Educational Rights and Privacy Act (FERPA); Study
Abroad and/or international travel program details including location(s), flight number(s), residence location and contact
information, itinerary, learning objectives, and any other information relating to the travel or program in which I am involved; inpatient and/or out-patient records including mental health records other than psychotherapy notes; admission and discharge records,
summaries and/or forms; patient information sheet; consent forms; authorization forms; patient questionnaires; patient history and/or
physical forms; operation admission and discharge records; operative reports; physician's notes; nurse's notes; skilled nurse's notes;
physician orders; observation notes; procedure notes; medication notes; physical therapy records or notes; rehabilitation records or
notes; social worker records or notes; face sheets; dictations; phone orders; lab reports; summaries; photographs; slides; pulmonary or
cardiac diagnostic test or procedure reports; consultation reports; progress notes or reports; status notes or reports; diagnoses;
treatment notes or reports; narratives; emergency room records; x-rays; CT scans; MRI scans; EEGs; EKGs; echocardiogram worksheets,
reports and tapes/films; V/Q scans and/or lung scan worksheets, reports, and tapes/films; sonogram or ultrasound worksheets, reports
and tapes/films; arteriogram worksheets, reports and tapes/films; cardiac catheterization worksheets, reports, tracings, and
tapes/films; pathology reports, samples, specimens, paraffin blocks, unstained and/or stained slides; written prescriptions and
triplicate forms; package inserts, patient information leaflets, sheets, and/or PPIs, or other information provided with prescriptions;
patient counseling records, documents used by pharmacist, pharmacist technicians or assistants giving counseling, copies of
prescription labels used on the bottle and package attachments showing dosage and instructions for administration of prescriptions;
external examination reports; toxicology reports; billing invoices, correspondence/memoranda, itemized statements, computer printouts, ledger cards, Medicare/Medicaid filing statements; correspondence from attorneys, other physicians, insurance companies,
Texas Workers' Compensation Commission, or Social Security Administration; notes or messages of telephone conversations;
handwritten notes; office notes; patient charts; test results or data; calendar entries reflecting scheduled appointments for the
patient. The information may be oral or written, and includes insurance records, including Medicare/Medicaid and other public
assistance claims, applications, statements, eligibility materials, claims or claim disputes, resolutions and payments, medical records
provided as evidence of services provided, and any other document or thing pertaining to services furnished under Title XVII of the
Social Security Act or other forms of public assistance (federal, state, or local). The term "correspondence" does not include
correspondence between the physician and/or health care provider and his/her/its legal counsel and/or malpractice insurance carrier.
Time Frame of Requested Information: Any records obtained by Stephen F. Austin State University regardless of the time in which such
records were actually created and/or obtained. Such time frame extends to include any record in University’s possession.
HIV/AIDS: I understand that the records used and disclosed pursuant to this authorization form may include information relating to:
Human Immunodeficiency Virus ("HIV") infection or Acquired Immunodeficiency Syndrome ("AIDS").
Drug/Alcohol Treatment Records: I understand that the records used and disclosed pursuant to this authorization form may include
information relating to treatment and counseling for drug and/or alcohol dependency.
Mental Health Records (including "psychotherapy notes" as defined under HIPAA): I understand that the records used and disclosed
pursuant to this authorization form may include mental health records and "psychotherapy notes" as that term is defined under HIPAA
and its promulgating rules.
I understand that I may revoke this authorization in writing at any time. I understand that I may revoke this authorization by sending or
faxing a written notice to the disclosing party identified above. This written revocation must state my intent to revoke this authorization.
However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and any revocation will not
affect those actions. Unless otherwise indicated this authorization shall remain active until I revoke this authorization as indicated above.
Office of International Studies and Programs – Study Abroad Application
PO Box 6152, SFA – Nacogdoches, Texas 75962-6152
936-468-2961/6604/6631
I understand that the entity to which this authorization is directed may not condition treatment, payment, enrollment or eligibility
benefits on whether or not I sign the authorization. I understand that the protected health information described above may be
redisclosed and no longer protected by federal and state privacy regulations.
I understand that by signing this authorization I am waiving my rights of nondisclosure of this information under federal law, including
the Federal Educational Rights and Privacy Act (FERPA), only as to the person(s) specifically listed above. This release does not permit the
disclosure of this information to any other persons or entities without my written consent.
Signature of Student or Student's Legal Representative:
Date: ________________________________________________
Printed Name:
Office of International Studies and Programs – Study Abroad Application
PO Box 6152, SFA – Nacogdoches, Texas 75962-6152
936-468-2961/6604/6631
HEALTH INFORMATION
This form is to be completed by the participant or parent/guardian (if student is under 18):
Student Name: ___________________________ Program: _________________________
Date of Birth: __________________
The purpose of this form is to help SFA to be of maximum assistance during your study abroad experience. Mild physical or psychological
disorders can become exacerbated with the stresses of life while studying abroad. It is important that the OIP be made aware of any
medical or emotional problems you have experienced. The information provided will remain confidential and will be shared with
program staff, faculty, or appropriate professionals only if necessary to your well-being. SFA may not be able to accommodate all
individual needs
or circumstances. This information does not affect your admission into the program.
Yes
No
1. Are you generally in good physical condition? (If no, please attach explanation.)
Yes
No
2. Have you ever been treated or are you currently being treated for any psychological
or emotional problems? (If yes, please attach explanation.)
Yes
No
3. Do you have any allergies? (If yes, please attach explanation.)
Yes
No
4. Are you taking any medications? (If yes, please attach explanation.)
Yes
No
5. Have you had major injuries, diseases, or ailments in the past five years? (If yes,
please attach explanation.)
Yes
No
6. Are you a vegetarian or are you on a restricted diet? (If yes, please attach explanation.)
Yes
No
7. Is there any additional information (concerning medical conditions or physical disabilities) that would be helpful
for the program to be aware of during your study abroad experience? (If yes, please attach explanation.)
Name and telephone number of physician: ___________________________________________
I certify that all responses made on this Health Information form are true and accurate, and I will notify the SFA Office of Study
Abroad Programs hereafter of any relevant changes in my health that occur prior to the start of the program.
Signature of participant: ___________________________________________
Parent/guardian’s signature (if student is under 18): _____________________
Date: _____________
Date: __________
Office of International Studies and Programs – Study Abroad Application
PO Box 6152, SFA – Nacogdoches, Texas 75962-6152
936-468-2961/6604/6631
Application Fee Payment Slip
DIRECT PAY
Fund: 150010 Org: 29101
Account: 51735
Program: R99
NAME: __________________________________________________
STUDENT ID: ____________________________________________
AMOUNT: $50 DATE: _________
Payment type:  cash  check  money order  credit card
Office of International Studies and Programs – Study Abroad Application
PO Box 6152, SFA – Nacogdoches, Texas 75962-6152
936-468-2961/6604/6631