APPLICATION PACKET FOR THE UNISSIST PROGRAMS
University of Northern Iowa System of Summer Institutes for Spanish Teachers
This application cannot be processed if you have not:
a. applied to Graduate Program: MA in Spanish (the thesis and emphasis in teaching options
are not available through UNISSIST)
b. completed all the information, signed and dated the application.
c. completed and sent (by separate e-mail to the appropiate director) the family form.
This application cannot be processed if it is not accompanied by:
a. all forms required by the Board of Regents, signed and dated (included with this
application)
b. the Policies Acknowledgment Form, signed and dated (included with this application)
c. a $50.00 check or money order (non-refundable; no carry over for following year). Please
write check to: UNISSIST Spain or UNISSIST Mexico.
Instructions:
1. Save this document as a Word document
2. Type in all the requested information
3. Print the forms
4. Sign and date the application and all the forms
5. Send application, forms and a $50.00 check or money order by regular mail to:
UNISSIST
234 Baker Hall
Cedar Falls, IA 50614
6. Go to http://www.uni.edu/modlangs/unissist/index.shtml, save the Family Form (Mexico or Spain) in a
Word document, type out all the information and send the form by e-mail (as an attachment) to the
appropiate director.
I. Please check status:
New student
I (am) applying for Degree Status
I (am) applying Non-degree Status
Returning student
Degree Status
Non-degree Status
Last time you participated in UNISSIST:
Place
UNISSIST Spain
UNISSIST Mexico
Year
II. Please check session(s) desired:
Session I
UNISSIST Spain
UNISSIST Mexico
UNISSIST Cedar Falls
Session II
Both sessions
III. Personal information
Name (legal)
Personal E-mail
Home address (complete)
Phone (include area code)
Date of birth
Place of birth
Name of School (where you
teach)
School Address
School Phone
E-mail
III. If applicable, please check:
If your participation is contingent on a grant, loan, fellowship or other factors which
have not yet been approved and include a note explaining your situation.
IV. Please indicate any special diet which must be followed, any physical or mental disabilities or
allergies, or special medications.
V. Please check:
I have read and accept the terms printed in the Policies Acknowledge Form
I have completed and signed the three forms required by the Board of Regents
I have completed and sent (by e-mail) the Family Form to the appropiate Director
The University of Northern Iowa requests this information for the purpose of processing your application for a
UNISSIST Program. No persons outside the University are routinely provided this information, except for items
of directory information such as name and local address. Release of any information is governed by the Board of
Regents rules and applicable state and federal statutes. Responses to items marked "optional" are optional;
responses to all other items are required. If you fail to provide the required information, the University may be
unable to process your application.
Signature of the applicant
Date
UNISSIST IN MEXICO
UNISSIST IN SPAIN
POLICIES ACKNOWLEDGEMENT FORM
UNISSIST institutes do not provide insurance. You are responsible for arranging for your own coverage.
The specific program and dates of the UNISSIST programs may be affected by alterations in transportation
services or by other causes. The right is reserved to make such alterations as may be found desirable or
necessary for the convenience of the program and for the efficient carrying out the of the program. The
University of Northern Iowa, the Director, faculty, or staff of the UNISSIST programs assume no liability for
any injury, loss, damage, accident, delay, irregularity, or additional expense arising from the use of any
vehicle or services, or from strikes, war, weather, quarantines, sickness, government restrictions or
regulations, or from any act of omission of any airplane, railroad, motor coach, or other transportation
company, or for any other cause whatsoever in connection therewith. Nor is any responsibility assumed in any
way for loss or damage of the UNISSIST program member's baggage or personal effects.
Participants accepted for the UNISSIST programs will be expected to comply with the requests of UNI for
filing of all data, transcripts, and other papers. Acceptance to the program will be provisional pending the
receipt of ALL required forms, duly signed.
The final cost of the abroad programs will depend on the total number of participants in both sessions. The
prices do not include: travel to and from the program sites to attend the Institute; books, medical insurance,
and incidental personal expenses. They do include: tuition, room and board for the abroad programs and
tuition only for the Cedar Falls program.
All prices are based upon current exchange rates between the foreign currencies and the U.S. dollar, and are
subject to confirmation and adjustment when the final payment for the Institute is made.
A $50 deposit must accompany the application form. This is required to hold a place for you in the Institute
and is not refundable. For participants in the abroad programs an $850 payment must be made upon
notification of acceptance, and a second $850 payment is required no later than February 1. The final payment
amount will be announced after April 1, and final payment will be due no later than April 15. Cancellations
after April 1 will incur a 10% service charge that will be deducted from the refund. After May 1 service
charge will be deducted from the refund. No refunds are possible after classes begin. Our program does not
accept payments by credit card or cash. Please pay by check or money order only.
If you are applying for Financial Aid, please note that you must be a "degree-status" student, i.e. one who is
seeking the M.A. degree. You must apply for Financial Aid at least four months before the starting date of
your program and the process must be complete before you leave the country. Please contact Financial Aid
directly for any and all questions, forms, etc. related to financial aid: 1 800 772-2736, 319 273-2700, 116
Gilchrist Hall, Univ. of Northern Iowa, Cedar Falls, IA 50614-0024, http://www.uni.edu/finaid.
Grades will be available to participants through the University of Northern Iowa Registrar's Office, and not
given to you on site. However, we will provide a statement confirming your completed course work at the end
of the summer session. We realize that several participants need official transcripts of their summer work for
their school system in order to receive salary increments. However, grades will not be turned in until after
October 1 and transcripts are not available for several weeks after that. Please note that we do not have
access to nor control over transcripts. Participants must order them directly. Please see
http://www.uni.edu/regist/students/transcripts.shtml.
Grade information: http://www.uni.edu/regist/students/grades.shtml.
The Department of Modern Languages does not support abusive use of either drugs or alcohol and therefore
expects that mature judgment be exercised while participating in our Study Abroad Programs. While alcoholic
consumption is socially accepted in other countries, inebriation by Program participants will not be tolerated.
As you are ambassadors of both the University of Northern Iowa and the Department of Modern Languages,
you must conduct yourself in a manner that will reflect positively on the department, the university and your
country.
Please note:

All UNISSIST in Mexico and UNISSIST in Spain participants are required to reside in
program-arranged housing during the dates of the program.

Acceptance to participate in a UNISSIST program implies strict observation of the starting
and ending dates. Arrival later than one day – due to travel delay – may result in cancellation
of program registration. Permission will not be granted for early departure.

There is a maximum of 10 credits for attending two sessions, and 6 credits for attending one
session.

Persons not registered with a UNISSIST program or employed by UNISSIST or by the
University of Northern Iowa will not be permitted to participate in any curricular or cocurricular activity.

A grade of “Incomplete” (I) will be given for all courses to those participants who have not
paid in full the costs of the program. Upon receipt of full payment the “I” designations will be
changed to the grades earned for each course.
Signature of the applicant
Date
HEALTH INSURANCE VERIFICATION
It is required that you have adequate health insurance coverage while studying or traveling abroad. Failure to carry
insurance can result in the delay or denial of treatment. Adequate health insurance provides coverage for: 1)
treatment and medications administered abroad; 2) emergency evacuation should you need to be rushed to a hospital abroad
or back to the U.S.; 3) repatriation of your remains in the event of your death.
Please complete:
Name: _______________________________
UNI Student Number*: _________________
Study abroad destination: _____________________ Dates: ________________________
Exact/complete name of abroad program: _____________________________________
Name of carrier company: _________________________________
Policy number: _________________
Name of insured: _______________________________________
My current insurance policy will cover me while abroad. Yes
Emergency evacuation provided: Yes
No
No
Repatriation provided: Yes No
Does your insurance provider require you to submit claim forms for services? Yes No
(If yes, make sure to pack them with your other important documents.)
I understand the need for health insurance and, if not already covered, will purchase a policy and provide the
necessary information to the Institutes Abroad Office. I certify that any policy I carry will be maintained for
the duration of my study abroad program. I further certify that the information I have provided above is
correct.
Signature: ___________________________________ Date: ___________________________
*UNI Student Number: We will fill this in if you do not have it.
EMERGENCY CONTACT INFORMATION
The following information is intended to be of assistance should an emergency situation occur either at home or abroad, before,
during or after the program. Please inform the program coordinator if any changes are to be made.
Person to contact in case of emergency:
Name(s): _____________________________
Emergency contact #2
Name(s): _________________________________
Relationship to you: _____________________
Relationship to you: _________________________
Street Address: _________________________
Street Address: _____________________________
City/State/Zip: _________________________
City/State/Zip: ______________________________
Home Telephone: (___)___________________
Home Telephone: (___)_______________________
Work telephone: (___)___________________
Work telephone: (___)________________________
Fax: (___)_____________________________
Fax: (___)__________________________________
E-Mail: _______________________________
E-Mail: ___________________________________
I give my permission to University of Northern Iowa and its agents to contact the person(s) I have identified as my emergency
contact in the event the program coordinator or agents of the University of Northern Iowa feel such action is justified.
Signature of applicant ___________________________ Date _____________________
UNI STUDY ABROAD PROGRAM
CONDITIONS OF PARTICIPATION STATEMENT
All applicants are asked to review and sign the following statement which constitutes conditions for participation in all
University of Northern Iowa sponsored study abroad programs.
1.
I understand and agree that, as a participant in the University of Northern Iowa study abroad program, I am subject
to the student conduct regulations described in the Student Information Handbook on the World-wide Web at:
http://www.uni.edu/vpess/handbook.html. I further understand that if I am attending a foreign university as part of
the University of Northern Iowa program, I am also subject to the conduct regulations of that institution.
2.
I agree to participate fully in all portions of the program and agree that any deviation I will make from the program
design must be approved in advance in writing by the program coordinator.
3.
I agree that the program coordinator may terminate my participation in the program if: 1) I engage in actions
endangering to myself or others; or 2) my conduct is considered to be detrimental or incompatible with the best
interest and welfare of the program. I further agree, if expelled from the program, to be responsible for all
expenses incurred in returning to the United States.
4.
I understand that I am subject to the laws of the host country and agree to abide by those laws. It is further
understood that the University of Northern Iowa may be limited in its ability to provide assistance in the event of
arrest and may also institute disciplinary proceedings.
5.
I am aware of the nature and the cost of the program. I shall be responsible for all financial obligations related to
my participation in the program.
6.
I agree to notify the program coordinator if I am planning extended individual travel during the program. Where
possible, I will provide the director with details of the proposed trip including plane, bus, and train schedules.
7.
I understand that the University of Northern Iowa reserves the right to cancel programs in the case of insufficient
participation or for reasons deemed appropriate. The University of Northern Iowa also reserves the right to make
changes to the program. I further understand that should the program, or any portion of the program, is changed or
cancelled, the University of Northern Iowa shall have no responsibility beyond the possible refund of deposits
made or monies paid to the University of Northern Iowa by the participants. Minor alterations in the program will
not result in refunds.
I have read, understand, and agree to the condition governing my participation in the UNI Study Abroad program. I further
understand the possible actions that will be taken should I act in a manner that is inconsistent with these conditions.
__________________________
Participant’s name (print)
__________________________
Participant’s signature
____________________
Date
__________________________________________________ ____________________
Parent(s) or Guardian(s) signature if under 18 years of age
Date
WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT
Please read this carefully. It affects any rights you may have if you are injured or otherwise suffer damages on a study and
travel program.
WHEREAS I, (print full name) __________________________________________________________
am about to participate in the study abroad program known as _________________________________
________________________________ and acknowledge that I understand that in consideration for my being
permitted to participate in said study program, I do hereby, for myself, the members of my family and spouse, and
my heirs, assigns, and personal representatives, acknowledge and assume the risk of participation in this study and
travel program and do hereby RELEASE AND FOREVER DISCHARGE the state of Iowa, Board of Regents,
State of Iowa, the University of Northern Iowa, and all their officers, faculty, employees, and agents (hereinafter
referred to as “Releasees”) whether accompanying said program or otherwise, from any and all claims, demands,
actions or causes of action on account of any injury to me or my property or on account of my death which may
occur from any cause during or relating to the said study program, or any continuances thereof; and I do hereby
expressly covenant and agree to refrain from bringing suit or proceedings at law or in equity or otherwise as
provided by law, against any of said bodies or persons on account of any and all such claims, demands, actions or
causes of action.
I further AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES from any loss, liability,
damage or cost, including court costs and attorney’s fees, that they may incur due to my participation in said
program.
MEDICAL AUTHORIZATION
If I incur or develop any injury or illness, then I hereby give my consent for medical treatment, and permission to
study program personnel to supervise and/or perform, as deemed necessary by study program personnel, on-site
first aid for minor injuries, and to a licensed physician or physician assistant to hospitalize and secure proper
treatment (including injections, anesthesia, surgery, or other reasonable and necessary procedures) for me. I agree
to assume all costs related to any such treatment.
IN SIGNING THIS AGREEMENT AND AUTHORIZATION I ACKNOWLEDGE AND REPRESENT THAT I have
read the foregoing Waiver of Liability and Hold Harmless Agreement, and Medical Authorization and understand it and
sign it voluntarily as my own, free act and deed; no oral representations, statements, or inducements apart from the
foregoing written agreement have been made; I am at least eighteen (18) years of age and fully competent (if not eighteen,
my parent(s) or guardian(s) agree with the terms of this document and sign it as such); and I execute this Agreement and
Authorization for full, adequate and complete consideration fully intending to be bound by same.
__________________________________________________
Participant’s signature
____________________
Date
__________________________________________________
Parent(s) or Guardian(s) signature if under 18 years of age
____________________
Date