Study Abroad Program Application
Please note the following must be submitted as part of the application package:
My application includes the following:
☐ Completed application
☐ Scanned copy of your passport (if you are in the process of applying for a passport please
note that in your application)
☐ Two Study Abroad Faculty Recommendation Forms
☐ Copy of your transcripts (These can be obtained in campus cruiser)
☐ $500 non-refundable deposit payable to EICC (by personal check or cash)
Applicant Information
Provide your name exactly as it appears/will appear on your passport.
First Name: Click here to enter text.
Middle Name: Click here to enter text.
Last Name: Click here to enter text.
Gender: Choose an item.
Birthday: Click here to enter a date.
Completion of this question is voluntary. Your cooperation is greatly appreciated and will not affect the
outcome of your application. Please check the box(es) that best describes your ethnic origin.
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African American
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Hispanic/Latino
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Other: Click here to enter text.
Asian or Indian Subcontinent
Multi-racial
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Caucasian
Native American
Addresses
Mailing address preference:
Present Address
Permanent Address
All program documents will be sent to the address you specify. If no preference is selected, all
documents will be mailed to your PRIMARY address.
Present Address
Last date to be reached at this address: Click here to enter a date.
Please provide mailing address at which you will be receiving mail from the time you complete this
application until one (1) week prior to program departure date (check your program dates).
Street Address: Click here to enter text.
City: Click here to enter text.
State: Click here to enter text.
Zip Code: Click here to enter text.
Permanent Address
Mail will be sent here after date given above. This must be filled out if you move from your present
address before program departure date. If you know at this time that you will be moving to another
location after your semester ends (and if it ends earlier than 1 week before your trip), please provide
address where you can be reached after you move at the end of semester.
Street Address: Click here to enter text.
City: Click here to enter text.
State: Click here to enter text.
Zip Code: Click here to enter text.
Email Address
School Email Address: Click here to enter text.
Alternate Email Address: Click here to enter text.
Do you permit EICC to give your email address to students participating in your program: Yes ☐ No ☐
You must provide your campus cruiser email address that you will check on a regular/daily basis in
order to receive critical program information from International office and lead program instructor.
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Phone Contact
Home Phone: Click here to enter text.
Cell Phone: Click here to enter text.
Other Phone: Click here to enter text.
Specify if other than home, cell, or your emergency contact’s phone: Click here to enter text.
College Information
College Campus: Choose an item.
College Instructor/Coordinator: Click here to enter text.
Major/Minor (if undecided, please say "General"): Click here to enter text.
Cumulative GPA: Click here to enter text.
Expected Graduation Date: Click here to enter a date.
Current Academic Level: Choose an item.
Academic Level While Abroad: Choose an item.
Academic Advisor: Click here to enter text.
Passport
Passport Processing Time Warning: if you need a new passport or need to renew an existing one, we
urge you to apply as soon as you know you want to travel on this program. Currently, an average wait
time for any new passport is about 2 months! (which you may not have if you submit right on the
application deadline). DO NOT DELAY receiving your passport as EICC will not refund any preliminary
fees to you should you miss the beginning of your program abroad due to late receipt of your passport.
Are you a US Citizen? Choose an item.
Do you have a valid US passport? Choose an item.
If yes, what is your passport number? Click here to enter text.
Passport expiration date: Click here to enter a date.
If not a US citizen, what is your country of citizenship? Click here to enter text.
Do you have a valid passport from this country? Choose an item.
If yes, what is your passport number? Click here to enter text.
Passport expiration date: Click here to enter a date.
EICC will need a COPY OF YOUR PASSPORT photo page at least 21 days (3 wks) before your program
departure date. Scanned/emailed copies are preferred. Please DO NOT FAX.
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Dietary and Medical Information
Special medical conditions: Click here to enter text.
(Required for emergency situations only. This information is kept confidential).
Medical Report
Studying in another country requires considerable adaptability. This is both part of the challenge and the regard.
Your willingness to answer these questions may assist us in organizing a successful program.
Study abroad requires a great deal of physical mobility. Do you have any physical limitations or
disabilities?
Are you generally in good physical condition?
Do you have any pre-existing conditions?
Have you had any major illness?
Have you ever had a major surgical operation or been advised to have one?
Have you ever been hospitalized?
Have you received treatment for drug or alcohol addiction?
Are you diabetic?
Do you have a heart condition?
Have you ever been treated for any mental or emotional disorder by a psychoanalyst or
psychologist?
Do you have any allergies to food, medications, environmental factors, animals, insects etc.?
Are you taking any medication?
Do you have any dietary restrictions? (Not all dietary restrictions may be accommodated
depending on the limitations of the local food supply. Please discuss with your college
instructor/coordinator.)
☐ Yes ☐ No
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☐ No
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☐ Yes ☐ No
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If you answered yes to any of the questions above please explain: Click here to enter text.
I certify that all responses made on this medical report for are true and accurate, and I will notify EICC
International Programs Offices hereafter of any relevant changes in my health that occur prior to the start of the
program. I understand that this form is for information purposes only and in no way implies that EICC takes
responsibility for my health.
Signed:________________________________________________________ Date: Click here to enter a date.
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Emergency Contacts
(Persons available 24/7 for contact during your specific program travel dates. At least one (1)
emergency contact must have medical power of attorney to make medical decisions on your behalf.)
Contact #1
First Name:* Click here to enter text.
Last Name:* Click here to enter text.
Relationship:* Click here to enter text.
Street Address:* Click here to enter text.
City:* Click here to enter text.
State:* Click here to enter text.
Zip Code:* Click here to enter text.
Email Address: Click here to enter text.
Daytime/Cell Phone:* Click here to enter text.
Evening/Cell Phone:* Click here to enter text.
Contact #2
First Name:* Click here to enter text.
Last Name:* Click here to enter text.
Relationship:* Click here to enter text.
Street Address:* Click here to enter text.
City:* Click here to enter text.
State:* Click here to enter text.
Zip Code:* Click here to enter text.
Email Address: Click here to enter text.
Daytime/Cell phone:* Click here to enter text.
Evening/Cell phone:* Click here to enter text.
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Personal Statement
Name: Click here to enter text.
College Campus: Choose an item.
In the section below please answer the following question in a clear, thoughtfully prepared short essay (about 300-500
words).
EICC offers the opportunity to immerse yourself in a host culture. However, it is your responsibility to make the most of this
experience. Introduce yourself and explain your academic goals for studying and for integrating into the host culture? What
specific situations from your past (i.e., coursework, job experience, travel, intercultural experience) have helped you
prepare to accomplish these goals?
Click here to enter text. Tips: 1. Show don’t tell 2. Consider your essay like a job interview 3. In previous experiences studying/traveling
abroad 4. Let your story convey a memorable impression 5. Be sincere, open, and creative 6. Be succinct.
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Waivers & Fee Information
The Waiver Form will need to be printed, signed by you and your college instructor, and mailed to the EICC
office. Once your participation is approved by your college instructor and once your application is completed,
please submit $500 non-refundable deposit payable to EICC (by personal check or cash) to secure your program
placement.
Waiver, Release & Indemnification Agreement
I understand that EICC and [other program participant colleges or organizations] may have to share educational
data about me as part of my participation in this Program. I authorize EICC [or other program participant
colleges or organizations] to share such educational data about me, including with my emergency contact
identified above, that are necessary to process my application, evaluate my performance, complete the
Program, and/or to assure my health or safety during the Program. I understand that if I do not consent to the
sharing of data about me, I cannot participate in this program.
I certify that all information is true and to the best of my knowledge. By signing this form, I give EICC [or other
program participant colleges or organizations] the right to access my records, transcriptions and any disciplinary
records. I understand that if I am accepted for a study abroad program that I will be a representative of EICC [or
other program participant colleges or organizations] and be subject to its rules and regulations we well as, the
rules and regulations of any host institutions abroad.
Model Release
I hereby consent to and authorize the use and reproduction by EICC or anyone authorized by EICC, of any and all
photographs, video and radio interviews, and surveys, which EICC has taken of myself, for any purpose
whatsoever, without compensation to me. EICC may use the photographs/quotes from surveys, for promotional
and information purposes through publications, broadcasts, and website for a period of two (2) years from the
date of my signature.
Medical Information
I understand that by applying for the Program and by paying the full Program Fee, additional overseas
Emergency Evacuation and Medical Insurance is to be obtained for me through EICC Office.
I understand that EICC does not have medical personnel available at the location of the Program, during
transportation, at the Host Institution/Affiliate or anywhere else where I may visit while a Participant in this
Program. I am responsible for all of my medical needs and medications while participating in the Program, and
am not relying upon anyone else therefore.
I agree that at its discretion, EICC [or other program participant colleges] may share my Student Medical Report
with the Host Institution/Affiliate, and/or Program Faculty. I hereby consent to such disclosure of this Medical
Report in connection with my participation in the Program, pursuant to the Family Educational Rights and
Privacy Act of 1974, as amended.
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Waiver of Liability
(Collect all signatures required)
Waiver, Release & Indemnification Agreement
I understand that EICC and [other program participant colleges] may have to share educational data about me as part of my
participation in this Program. I authorize EICC [or other program participant colleges] to share such educational data about
me, including with my emergency contact identified above, that are necessary to process my application, evaluate my
performance, complete the Program, and/or to assure my health or safety during the Program. I understand that if I do not
consent to the sharing of data about me, I cannot participate in this program.
I certify that all information is true and to the best of my knowledge. By signing this form, I give EICC [or other program
participant colleges] the right to access my records, transcriptions and any disciplinary records. I understand that if I am
accepted for a study abroad program that I will be a representative of EICC [or other program participant colleges] and be
subject to its rules and regulations we well as, the rules and regulations of any host institutions abroad.
Signed:_____________________________________________ Date: ______________________________
Registration & Payment
I agree to pay the Non-Refundable deposit at time of application, plus any and all program fees by stipulated due date.
Signed:______________________________________________ Date: ______________________________
Model Release
I hereby consent to and authorize the use and reproduction by EICC or anyone authorized by EICC, of any and all
photographs, video and radio interviews, and surveys, which EICC has taken of myself, for any purpose whatsoever, without
compensation to me. EICC may use the photographs/quotes from surveys, for promotional and information purposes
through publications, broadcasts, and website for a period of two (2) years from the date of my signature.
Signed:______________________________________________ Date: ______________________________
Medical Information
I understand that by applying for the Program and by paying the full Program Fee, additional overseas Emergency
Evacuation and Medical Insurance is to be obtained for me through EICC Office.
I understand that EICC does not have medical personnel available at the location of the Program, during transportation, at
the Host Institution/Affiliate or anywhere else where I may visit while a Participant in this Program. I am responsible for all
of my medical needs and medications while participating in the Program, and am not relying upon anyone else therefore.
I agree that at its discretion, EICC [or other program participant colleges] may share my Student Medical Report with the
Host Institution/Affiliate, and/or Program Faculty. I hereby consent to such disclosure of this Medical Report in connection
with my participation in the Program, pursuant to the Family Educational Rights and Privacy Act of 1974, as amended.
Signed:______________________________________________ Date: _______________________________
Instructor Approval
Application will not be accepted without instructor signature.
Name: Click here to enter text.
Title: Click here to enter text.
College Course you will register for: Click here to enter text.
Instructor Signature:____________________________________ Date: _______________________
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Study Abroad Faculty Recommendation Form
To be Completed by Student
Program: Click here to enter text.
Name of Student: Click here to enter text.
To be Completed by Faculty Member
How long and in what capacity do you know the Applicant?
☐Current Student of mine
☐Previous Student of mine
☐Other
According to the following criteria, how would you evaluate the applicant’s readiness for study abroad?
Unable to Low Acceptable
Very
Excellent
Evaluate
Good
Motivation for study abroad
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Academic performance
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Emotional Stability and Maturity
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Respect for customs, rules and values of others
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Ability to handle stress
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Flexibility
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Self-reliance and independence
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☐ I recommend this applicant without reservation
☐ I recommend this application with reservation
☐ I do not recommend this applicant
Please describe:
Printed Name of Faculty: __________________________________________ Date: __________________
Signature of Faculty: _______________________________________
Please return to the International Programs Office by: Click here to enter a date.
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Study Abroad Faculty Recommendation Form
To be Completed by Student
Program: Click here to enter text.
Name of Student: Click here to enter text.
To be Completed by Faculty Member
How long and in what capacity do you know the Applicant?
☐Current Student of mine
☐Previous Student of mine
☐Other
According to the following criteria, how would you evaluate the applicant’s readiness for study abroad?
Unable to Low Acceptable
Very
Excellent
Evaluate
Good
Motivation for study abroad
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☐
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Academic performance
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Emotional Stability and Maturity
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Respect for customs, rules and values of others
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Ability to handle stress
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Flexibility
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Self-reliance and independence
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☐ I recommend this applicant without reservation
☐ I recommend this application with reservation
☐ I do not recommend this applicant
Please describe:
Printed Name of Faculty: __________________________________________ Date: __________________
Signature of Faculty: _______________________________________
Please return to the International Programs Office by: Click here to enter a date.
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