WESTFIELD STATE UNIVERSITY
SHORT-TERM PROGRAM APPLICATION
Eligibility requirements for application to Westfield short-term Education Abroad Programs:
 A currently enrolled Westfield student
 Must have 24 earned hours**
 Must have at least a 2.25 gpa**
** These requirements are waived for First-Year students applying to approved programs.
Application/Payment Deadlines:
Applications are being accepted now on a first-come, first-accepted basis.
Space is limited to approximately 16 students per course!
For January travel:
Application and $500 deposit deadline:
Balance due by:
October 15, 2012
November 16, 2012
For May travel:
Application and $500 deposit deadline:
Balance due by:
December 14, 2012
February 15, 2013
A Payment Plan is available: $550 deposit is due at application; contact Danielle Emerson for information.
Application Process
Step I
 Complete this application and submit with the $500 deposit fee to International Programs Office.
Step II
 You must meet with the Faculty Member who is instructing the course and have the attached Reference Form completed.
Submit the reference form in a sealed and signed envelope, or request that it be emailed directly to
demerson@westfield.ma.edu
Step III
 You will be notified in writing of your acceptance into the short term course; a course syllabus will be sent to you as well.
Step IV
 You will receive an email with the following forms attached: Emergency Contact form, Health form, and Student
Participation Agreement form. You must complete and return the forms to the International Programs Office, with
a color copy of your Passport. (Driver’s license required for Domestic courses).
Step V
 Pay your balance by the above due date!
For questions, please contact Danielle Emerson at:
demerson@westfield.ma.edu or 572-8035 or visit us in the Parenzo Lobby.
A journey of a thousand miles begins with one step. Take your first step now into Parenzo 130!
FACULTY INFORMATION:
COURSE LOCATION
INSTRUCTOR CONTACT INFORMATION
BELIZE
Brian Conz, Assistant Professor, Geography and Regional Planning
bconz@westfield.ma.edu t: (413) 572-8084
COSTA RICA
(BIOLOGY)
Tim Parshall, Associate Professor, Biology
tparshall@westfield.ma.edu t: (413) 572-5303
COSTA RICA
(EDUCATION)
Trudy Knowles, Professor, Education
tknowles@westfield.ma.edu t: (413) 572-5724
FRANCE
Barbara Keim, Professor, Art
bkeim@westfield.ma.edu t: (413) 572-5328
GHANA
Kamal Ali, Professor, Ethnic and Gender Studies
kali@westfield.ma.edu t: (413) 572-5388
ITALY
Mark Abate, Professor, Chair, History
mabate@westfield.ma.edu t: (413) 572-5345
MOROCCO
Daniel Price, Assistant Professor, Criminal Justice
dprice@westfield.ma.edu t: (413) 572-8146
NEW ORLEANS
Edward Orgill Assistant Professor, Music
eorgill@westfield.ma.edu t: (413) 572-8196
Katheryn L. Bradford, Director Alumni Relations, Horace Mann Center 245
kbradford@westfield.ma.edu t: (413) 572-5404
NICARAGUA
Kelli A. Nielsen, Adjunct Faculty
Office hours available weekly, Horace Mann Center Lobby
Kellinielsen5@gmail.com t: (413) 977-2895
Robert Hayes, Professor, Psychology
rhayes@westfield.ma.edu t: (413) 572-5380
SAN FRANCISCO
Nanci Salvidio, Interim Vice President, Advancement and University
nsalvidio@westfield.ma.edu t: (413) 572-8123
U. S. SOUTHWEST
ARIZONA & NEW MEXICO
Michael Young, Associate Professor, Physical Science
myoung@weswtfield.ma.edu t: (413) 572-5741
Tarin Weiss, Assistant Professor, Physical Science
tweiss@westfield.ma.edu t: (413) 572-8269
Aaron Reyes, Assistant Professor, Physical Science
aoreyes@westfield.ma.edu t: (413) 572-8903
APPLICATION
Please enter all information completely and legibly by typing or printing in ink. Please complete and return to the International Programs Office in Parenzo 130 (lobby)
CWID:
A
Today’s Date:
Date of Birth:
Gender:
Male
Female
Legal Name as it appears on your Passport:
(family/Last)
(given/First)
(middle)
Address
City
State
Zip:
Permanent Street Address
WSU Email:
@westfield.ma.edu
Cell Phone:
Other email:
Home Phone:
TRAVEL IN JANUARY 2013
Please check the course(s) for which you are applying:
Semester
Location
Course #
Course Title
Fall 2012
Costa Rica
BIOL 0102*
Environmental Biology (Lab Science Core course) or
Costa Rica
BIOL 0279
Special Topics: Environmental Science: Costa Rica
Semester
Location
Course #
Winter 2013
Ghana
EGST 0230*
Ghanaian Arts
Nicaragua
SLTS 0201*
Service Learning Travel Seminar: Nicaragua
Course Title
*First year students may apply
Semester
TRAVEL IN MAY 2013 Please check the course(s) for which you are applying:
Location
Course #
Course Title
Spring 2013
Belize
GARP 0239
Bio-Cultural Diversity & Community-Based Conservation
Italy
HIST 0101*
Western Experience I or
Italy
HIST 0213
World History or
Italy
HIST 0300
Ancient Rome to the Italian Renaissance
San Francisco
SLTS 0202*
Service Learning Travel Seminar: San Francisco
U.S. Southwest
______GEOL 0211
Geology in the Field: the Southwest
Semester
Location
Course #
Course Title
Summer 2013
Costa Rica
EDUC 0398
Intercultural and Tropical Ecology Experience (UG) or
Costa Rica
EDUC 0598
Intercultural and Tropical Ecology Experience (GR)
France
ART 0107*
Art Survey II Impressionist and Expressionists (UG) or
France
ART 0522
Women Artists in the Western World (GR)
Morocco
CRJU 0347
ST: Law and Criminal Justice in Islam
*First year students may apply
Academic and Student Conduct
I have a satisfactory academic and student conduct record at Westfield State University, have not been convicted of any crime, and have no outstanding
proceedings pending before any judicial or collegiate body against me.
___ Yes ___ No (If checked, please explain on a separate sheet).
I have not been found guilty of any academic dishonesty at Westfield State University.
___ Yes ___ No (If checked, please explain on a separate sheet).
Disability/Learning Disability/Medical information
The University welcomes students with disabilities and strongly encourages disclosure of any disability or medical condition which may impact your
studies. Declaring a disability will not affect the academic decision about your application, but will help us put in place any individual arrangements or
accommodations necessary for your study abroad program at Westfield State University.
Students who receive services for Learning or Physical disabilities must submit with their application a participation recommendation from their
Program Advisor and a request for academic accommodation (if needed). These forms are located in the International Programs Office and in the
Banacos Academic Center.
Please check at least one of the following:
□ I am not aware of any conditions which would prevent me from fully participating or which may disadvantage the progress of the study abroad
group.
□ Specific Learning Disability, e.g. dyslexia
□ Blind/partially sighted
□ Deaf/hearing impairment
□ Wheelchair user/mobility difficulty
□ Mental health difficulties
□ Medical disability e.g. diabetes, epilepsy, asthma
□ Autistic spectrum disorder
□ Non-verbal learning disability
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I understand the University will access my student transcript in consideration of participating in this program.
Initials

I understand I am required to attend orientation programs prior to participation in this program.
Initials

I consent to the release of any and all information contained in my Westfield State University student conduct
file to the Director of International Programs and any other WSU faculty and staff that the director may deem
appropriate for the purposes of this program application.
Initials
My signature below indicates that I am aware that there will be no refund should I withdraw from the class 45 days
to departure or less. I will be held responsible for full payment of the course and all penalties and fees that occur due
to my withdrawing from the class. I understand that any money owed to Westfield State University will be applied to
my student account and I will be unable to register until my account is paid in full.
Initials

The answers I have given are correct to the best of my knowledge. I understand that should any of the information included on this form be found to
be materially inaccurate, it may serve as the basis for rejection or removal from the short-term program.
(Signature of Student)
(Date)
FOR OFFICE USE ONLY:
________
________
GPA
Class level
Faculty Reference
Accommodations needed
Deposit paid
Balance paid
FACULTY REFERENCE FORM
Student’s Name:
CWID A
Location, title and semester of short-term course
Academic Status: ___ First-year ___ Sophomore ___ Junior ___ Senior ___Graduate student
Major (or intended major):
Dear Faculty Member:
Expected Graduation Date
The individual named above has applied to participate in your Short-Term course.
We appreciate your candid assessment of this student’s academic motivation and ability,
class performance, and his/her overall potential for successfully adapting to study and life in a foreign country.
Once completed, please enclose this form in a signed and sealed envelope and send to:
Danielle Emerson, International Programs, Parenzo 130.
You may also scan and email to Danielle at demerson@westfield.ma.edu.
Please complete the rating scale by placing checkmarks in the appropriate locations.
Please assess this student’s suitability to participate in a short-term study abroad course:
No Basis for
Evaluation
Below
Average
Average
Ability to participate in physically
challenging situations
Ability to participate in social
situations with strangers
Ability to adjust to new and foreign
situations
Ability to work within a team
Ability to conform to authority
Self-Confidence and Maturity
Independence and Flexibility
Oral and Written Expression
Additional comments section and signature section found on the reverse side of this form.
Above
Average
Outstanding
Please add any additional comments you feel will assist the International Programs Office in evaluating the applicant.
Please print your name:
Department
Telephone:
Signature:
Email:
@westfield.ma.edu
Date: