Study Abroad Application
Affiliate or Exchange Program
For any programs not listed on the study abroad website, you must secure approval from International
Affairs. Please call434.395.2172 for an appointment with the Executive Director. Complete all fields of
this application. Please fill-in the text fields and then print and sign. A legal guardian must sign as
well. Submit to International Affairs (Stevens Hall).
Your name:
DESTINATION INFORMATION
Country of destination:
City of destination:
Indicate type of program:
Longwood exchange program at partner institution (Nantes, Oldenburg, HAN, Derby, etc.)
-Indicate full name of partner university you will attend:
Program offered by an affiliate or non-affiliated company or organization (ISS, ISA, CIS, etc.)
A. Indicate name of affiliate/non-affiliate program provider:
B. Check which one applies:
I will be taking classes at a foreign institution
-IF SO, indicate full name of the school or institute:
I will be performing an internship
-IF SO, indicate full name of the company or organization if known at this
point:
I will be completing student teaching or a practicum
-IF SO, indicate full name of the school or institute where you will be
teaching:
Timeframe for Travel:
Approx. dates of travel:
Year;
Fall;
Spring;
Summer
Departure:
Month
Year
Return:
Month
Year
Are you participating in the Virginia Pre-Paid Education Program?
Yes
No
BIOGRAPHICAL INFORMATION
(Legal) First name:
Middle:
Last:
Nickname:
Do you attend Longwood? Yes If no, please name institution:
Your address at college:
Your permanent address:
L number:
Phone:
Email:
Month of birth:
Day:
Year:
Place of birth:
US Citizen: Yes
No
--If not American citizen provide country:
What type of visa?
Do you have passport: Yes
No
--If yes provide number:
Expiration:
Where issued:
Your marital status: Single
Are you an international student on a visa? Yes
No
Ethnicity (for reporting purposes only):
Hispanic/Latino
Non-Hispanic/Non-Latino
If you chose “Non-Hispanic/Non-Latino” please select one or more of the following that best
describes your racial group:
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific Islander
Black or African American
White
Choose not to disclose
ACADEMIC INFORMATION
Current classification: Freshman
Class when you will be when studying abroad:Freshman
Major(s):
Minor(s):
GPA:
Anticipated Graduation Date: January Year:
Have you ever been found guilty in a judicial or honor code violation? Yes
--If yes to above please explain:
Courses you plan to enroll in while abroad:
1.
2.
3.
4.
5.
EMERGENCY CONTACT INFORMATION
Contact #1
First name:
Home phone:
Cell phone:
Relation to you:
Is this individual a legal guardian?
Last:
Work phone:
Email:
Yes
No
Contact #2
First name:
Home phone:
Cell phone:
Relation to you:
Is this individual a legal guardian?
Last:
Work phone:
Email:
Yes
No
AGREEMENT AND RELEASE
I certify the above information is complete and correct. I understand that any misrepresentation may result in my
dismissal from the program. I understand that any request to participate in a non-affiliate program must be approved
by International Affairs. I understand that I am responsible for attending a Risk Management session delivered by
the Office of International Affairs. I am also required to have medical coverage that meets the minimum standards
set forth by that office. I must work closely with the Study Abroad office and International Affairs to ensure that I
submit all required documents. I hereby apply to the Longwood University program and authorize the release of any
information necessary to complete the application.
Applicant’s signature ________________________________________Date _____________________
PARENT STATEMENT
Parents and/or Guardians, please read and sign the following, even if your son or daughter is over 18 years of age.
Your support of your son/daughter’s desire to study abroad is important. Thank you.
1. I have read and signed the Conditions of Participation.
2. I have read and understand the study abroad program refund policy.
3. I understand that even mild physical and emotional problems may be exacerbated by the stress associated with
travel and adjusting to a new cultural environment. I believe that my daughter’s/son’s decision to undertake this
experience at this time is a sound one.
Parent’s signature: _____________________________________________Date: ___________________
(Students, it is a violation of the honor code to sign on behalf of a parent/guardian. This must be
signed by someone who is legally responsible for you.)