Office of International Programs
2700 Evergreen Pkwy NW, LIB 2153, Olympia, WA 98505
Tel: 360-867-6421
Fax: 360-867-5343
Application for Evergreen Exchange Programs
*** PLEASE PRINT ***
Name: _____________________________________________________ Phone: ________________________________
Student ID number: ______________________________ Email Address: _______________________________________
Birth Date: ____/____/____
Current Class Level: ___FR
Receiving Financial Aid?
□Yes □No
___SO ___JR ___SR ___GR
Receiving Pell Grant ?
□Yes □No
Expected Graduation Date: ______________________
Current Academic Emphasis: ________________________________________ Total Credits Earned So Far: __________
Have you ever been on academic warning?
□
□
No
Do you have any disciplinary history at Evergreen?
□
Yes
No
If yes, when? __________________________________
□
Yes
If yes, what/when? _______________________
__________________________________________________________________________________________________
Indicate the Exchange Program you are applying for:
___ University of Miyazaki
Miyazaki, Japan
Oct 1 - Aug 31
Deadline to Apply: Feb 1
___University of Hyogo
Kobe, Japan
Apr 1 – Mar 31
Deadline to Apply: May 1
___Daejeon University
Daejeon, South Korea
Fall Semester
Spring Semester
Deadline to Apply: Mar 15
Deadline to Apply: Aug 15
___UW Jackson School
Seattle, WA, USA
Sep 15-Jun 15
Deadline to Apply: Mar 15
___University of Roskilde
Roskilde, Denmark
Fall Semester
Spring Semester
Deadline to Apply: Mar 15
Deadline to Apply: Aug 15
Please estimate and circle your current level of target language ability according to the scale below:
Target Language?
0
__________________ None
1
2
3
Beginning Levels
1
2
3
Intermediate Levels
1
2
3
Advanced Levels
Describe your plans for developing your target language skills prior to participation in the program.
__________________________________________________________________________________________________
Rev.11/13/15
List the two people you plan to request recommendation letters from:
Name: __________________________________________________________ Relationship _____________________
Name: __________________________________________________________ Relationship _____________________
Please include the following required items along with this application. Remember to sign and date your application
below.
___
One-page letter of interest, single spaced, indicating your reasons for applying, your goals, why you feel you are
prepared, any projects you will undertake, and any indicators of maturity, responsibility, and leadership.
___
Two signed recommendation letters from those listed above, either in sealed, signed envelopes, or sent directly
to clifthom@evergreen.edu via email. The standard recommendation forms included may also be used.
___
Unofficial Evergreen transcript, or if you do not yet have one, official transcripts from other institutions where
you earned 45 or more credits.
___
A printout of your Academic History from your my.evergreen.edu account.
___
One academic writing sample, 5-10 pages long, that shows research, analysis, or argument. No creative writing.
___
An additional Language Assessment Form is currently required for programs in Japan.
___
The Review Committee may also request an interview with each applicant, at their discretion.
_________________________________________________________________________ Date: ___________________
Student Signature
Return completed form and required items to:
International Programs & Services • LIB 2153
The Evergreen State College
2700 Evergreen Parkway NW
Olympia, WA 98505
Fax: 360-867-5343 • clifthom@evergreen.edu
Office Use:
Academic Warning
□
Disciplinary Record
□
Academic History
□
Evergreen Exchange Programs Recommendation Form
____ Daejeon University, Daejeon, South Korea
____University of Miyazaki, Miyazaki, Japan
____University of Hyogo, Kobe, Japan
____Roskilde University, Roskilde, Denmark
____ University of Washington Jackson School, Seattle, WA
Name of Student ______________________________________________________________________________
Recommender’s Name _________________________________________________________________________
The above student is an applicant to the Evergreen Exchange Program listed above. This program will entail one or two
semesters of overseas study and the ability to live relatively autonomously. Participants must be highly motivated,
emotionally mature, resilient over an extended time, and able to adapt easily to people with different social and cultural
backgrounds. In addition, students are representatives of the Evergreen State College and participate in presentations
about American culture to overseas communities.
Please be as candid as possible in your appraisal of the applicant’s suitability for this program. Indicate your assessment
in the space below, using the reverse side for additional comments as needed, or you may attach a separate prepared
page.
Please return this form to the student in a sealed, signed envelope, or you may deliver it to Michael Clifthorne, Office of
International Programs, The Evergreen State College, Library 2153, 2700 Evergreen Pkwy NW, Olympia, WA 98505.
Thank you for your assistance with this recommendation.
1. In what capacity and for how long have you known the applicant:
2. Circle one letter for each category below. Please use the following scale in your assessment:
A = top 10%
B = top 30%
Intellectually curious
Emotionally mature
Independent worker
Self-reliant
Self-assured
Adaptable
Cooperative
Well-mannered
C = top 70%
ABCDEX
ABCDEX
ABCDEX
ABCDEX
ABCDEX
ABCDEX
ABCDEX
ABCDEX
D = bottom 30%
E = botton 10%
X = no opinion
Comments__________________________________________
Comments__________________________________________
Comments__________________________________________
Comments__________________________________________
Comments__________________________________________
Comments__________________________________________
Comments__________________________________________
Comments__________________________________________
Please check the appropriate box:




I highly recommend the applicant
I recommend the applicant
I recommend the applicant with reservation: _______________________________________________
I do not recommend the applicant
Please add any additional comments here, or attach a separate sheet:
____________________________________________________________________________________
Signature
Date
____________________________________________________________________________________
Name (please print)
Position or title
____________________________________________________________________________________
Office address
Phone