Roane State Community College Study Abroad Programs
APPLICATION
Program: _________________________________
Dates of the Program ______________________ Application due: ____________________
Last Name: _________________ First Name: __________________ Middle Initial:____
Gender: M___F___ Do you have a valid passport? Yes __ No __Date of Birth: ( /
/
Social Security Number:______ ____ _____ Academic Advisor:___________________
Street Address: ________________________________________ City: _______________
State ___ Zip Code: ____________ Citizenship: _________ Phone: (____) _____ _______
Email Address: _________________ Do you have foreign language skills? Yes___No ___
)
EMERGENCY CONTACT (We encourage you to discuss this Responsibility first)
1) Name _______________________________________ Relationship _______________
Address__________________________________________________________________
City _________________________ State _______________ Zip ___________________
Home Phone _______ _________ ______ Cell Phone: _______ _________ ______
E-mail address ___________________________________________________________
Describe what you hope to gain from this experience and how it will benefit your educational and career
objectives._________________________________________________________________
_________________________________________________________________
Student Conduct Agreement
I have read the “Student Conduct and Disciplinary Sanctions”(Policy # SA- 06-01 Part 4) as explained in
the Roane State Community College catalog. I understand that I will be representing the entire student
body of Roane State Community College and I have the obligation to follow the school rules. I promise to
show good judgment in all of my behavior during the length of the trip. I realize that this is a nonalcoholic trip and also realize that illegal drugs will not be tolerated. I understand that this program has
educational activities that I should not miss. During the length of the program, I will comply with the
syllabus requirements and will participate in all the cultural opportunities offered to me .I realize that it
may not be safe to wander around alone. I will always, at all times, stay with other people involved in the
program, whether Roane State students, RSCC faculty, or the in country hosts. I will follow all the
instructions and directions given by the Roane State Community College faculty member(s) while
traveling during this Study-Abroad Program. By signing this agreement, I understand that if I choose
not to follow the expected conduct I may be sent back home at my own expense and I will face
disciplinary action upon returning to Roane State.
______________________________
Student
__________________
Date
______________________________
Faculty Representative
__________________
Date
RSCC Study-Abroad Participant Student Medical History Form
Name ___________________________________________________ Program________________
1. Blood type ___________
2. What illnesses, conditions or injuries have you had medical treatment for in the past five years?
_______________________________________________________________________________________
_______________________________________________________________________________________
3 Are you currently under treatment for any physical or emotional condition? Please explain.
________________________________________________________________________________________
________________________________________________________________________________________
4.List any ongoing physical or emotional conditions which might require immediate treatment abroad due to changes in
climate, diet or exercise. What treatment is recommended?
__________________________________________________________________________________________
5. Are you currently taking any medications on a regular basis? If so, please name.
________________________________________________________________________________________
Please describe for what purpose the medication is prescribed (e. g. Claritin for allergies)
________________________________________________________________________________________
6. Which medications are you allergic to? _____ aspirin _____ sulfa drugs
_____ penicillin
( Other? please name)
______________________________________________________________________________________
7. Do you wear contact lenses? _______________________________________________________
8.What other substances are you allergic to? (i.e. bee stings, foods, plants, animals, etc.)
____________________________________________________________________________
9 Do you have any condition which might prevent you from participating in excursions or other activities?
_____________________________________________________________________________________
10. Are you on a restricted diet? If so, give details.
___________________________________________________________________________________
11.Your physician: Name ______________________________________ Telephone ( ___)___________
Please complete the section below if you are covered by private health insurance. If you do not have health
insurance coverage, check the box indicating that you will be covered by the basic coverage provided to all holders
of the International Student Identity Card (RSCC issued) and sign.
This is to State that Group Policy number ___________________has been issued to:_________________
by:_________________ providing insurance protection for medical emergencies during travel abroad. This policy will be
in full force and effect during the time of enrollment in the RSCC study-abroad program
Does the above policy cover Sickness/hospitalization?
____yes ____no
these expenses incurred in Doctor’s visits
____yes ____no
another country?
Medical evacuation?
____yes ____no
Repatriation of remains?
____yes ____no
*Please indicate your medical insurance carrier’s procedure for handling claims in the event that you require medical
care while overseas:
____ I must pay cash to service provider and submit paid receipts to insurance company for reimbursement
____ The insurance company will deal directly with medical service provider in another country.
____I am not covered by private insurance. I understand that my International Student Identity card provides a basic
accident/health insurance coverage.
___________________________
__________________
Participant’s Signature
Date
* It is important to be aware of what procedures for payment/reimbursement will be required by your particular medical insurance company. Most U.S. companies will
not make payment directly to a foreign doctor or hospital. In the event of illness or accident, students must be prepared to pay cash to the foreign doctor or hospital, and
be responsible for obtaining receipts to submit for reimbursement by their U.S. medical insurer. BE PREPARED BY KNOWING YOUR INSURER’S GUIDELINES!