Travel-Study Program Application Form

Travel-Study Program
Application Form
Belgium 2015 – POLS 298.3
NAME OF PROGRAM:
FACULTY COORDINATOR: DR. MARTIN GAAL
E-MAIL: martin.gaal@usask.ca
DEPARTMENT: POLITICAL STUDIES
TELEPHONE: 966-4121
PLEASE RETURN APPLICATION TO THE PROGRAMS OFFICE, ATTN: ANDREA ECCLESTON
E-MAIL: andrea.eccleston@usask.ca
TELEPHONE: 306-966-4194
IN PERSON: ARTS 515
ADDRESS: PROGRAM OFFICE, ARTS ROOM 235, U OF SASKATCHEWAN, 9 CAMPUS DRIVE,
SASKATOON SK S7N 5A5
APPLICATION DEADLINE DATE: FEBRUARY 1 2015
INSTRUCTIONS TO THE APPLICANT:
PLEASE PRINT ALL INFORMATION LEGIBLY.
SUCCESSFUL APPLICANTS WILL BE REQUIRED TO COMPLETE AND SUBMIT AN INTENT TO PARTICIPATE FORM ALONG
WITH THE NON-REFUNDABLE DEPOSIT BY THE DEADLINE DATE SPECIFIED IN THE ACCEPTANCE LETTER. SUCCESSFUL
APPLICANTS WILL BE RESPONSIBLE FOR COMPLYING WITH ALL TASKS STATED IN THE ACCEPTANCE LETTER.
CHECKLIST OF SUPPORTING DOCUMENTS REQUIRED:
PLEASE ENCLOSE ALL DOCUMENTS AT THE TIME OF APPLICATION AND ENSURE TO SUBMIT APPLICATION BY THE DEADLINE DATE.
□ APPLICATION FORM
□ RESUME
□ ACADEMIC REFERENCE (ONE)
□ TRANSCRIPTS (UNOFFICIAL COPY FROM PAWS)
□ COPY OF PASSPORT ID PAGE
SECTION ONE: PERSONAL AND ACADEMIC INFORMATION
Name of Applicant:
Gender:
FIRST & LAST NAMES (EXACTLY AS THEY (WILL) APPEAR ON YOUR PASSPORT)
Telephone Number during
academic year:
Address during academic year: (INCLUDE POSTAL CODE)
Permanent Telephone Number:
Permanent Address – If different from above: (INCLUDE POSTAL CODE)
Cell Phone Number:
Student Number:
College:
Date of Birth:
______/______/______
day
month year
E-Mail:
Major:
Completed credit
units to date:
Anticipated
Graduation Date:
Will this course(s) count towards
your major or as an elective?
NOTE: The U of S communicates with students through PAWS
Major
Elective
and the student's U of S assigned e-mail account (nsid@mail.usask.ca). It
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the student's responsibility to read mail sent to that account and attend to i
Passport Number:
Country of Issue:
Valid until: (INDICATE DATE AS IT APPEARS ON PASSPORT)
PASSPORTS MUST BE VALID FOR SIX MONTHS PAST YOUR INTENDED DATE OF RETURN. W E REQUIRE
A COPY OF THE INFORMATION PAGE FOR OUR FILES. PLEASE SUBMIT WITH APPLICATION.
Nationality:
Name of Emergency Contact Person: ___________________________________
Relationship: ________________________________
Address: ___________________________________________________________________________________
Telephone: __________________________________
Yes
No
Do you have any allergies or dietary restrictions of which we should be aware?
IF YOU ANSWERED ‘YES’ PLEASE PROVIDE DETAILS BELOW OR IF YOU NEED ADDITIONAL SPACE ATTACH A SEPARATE SHEET:
___________________________________________________________________________________________
___________________________________________________________________________________________
Yes No Will you be asking for any special accommodations (ie: related to a medical condition, disability, etc) during the course of this Study
Abroad Program? If yes, please contact:
Andrea Eccleston
Program Coordinator
Andrea.eccleston@usask.ca
with the details of the request and supporting documentation for the request (ie: DSS forms, doctor’s note, etc).
Have you lived or traveled outside of Canada before? If yes, please indicate where, when, length of time:
Traveled: ________________________________
________________________
__________________
Studied: _________________________________
________________________
__________________
Worked: _________________________________
________________________
__________________
Have you previously participated in a University-level study abroad program?
Yes
No
( IF ‘YES’, PLEASE PROVIDE BASIC DETAILS – PROGRAM NAME, HOST COUNTRY, YEAR(S) OF TRAVEL)
Which of the prerequisite courses specified for this program have you taken or are you in the process of
completing? Please specify if completed or in progress.
If you do not/will not have completed the necessary prerequisite courses, indicate equivalent courses and/or
equivalent qualifications:
SECTION TWO: BUDGETING
This section does not have to be submitted with the application but allows the student a chance to explore the
financial aspects of the studying abroad. By using the Budget Framework information created by the
International Student and Study Abroad Centre (http://students.usask.ca/money/budgeting.php), estimate the
cost of your study abroad program. Not all categories may be applicable to a Faculty-led Taught Abroad
program.
NOTE: If accepted, students will be required to register in and pay U of S tuition for the course(s) in which they
are participating, in addition to the program fee and additional costs such as airfare, meals, etc. Specific details
will be provided in the acceptance letter.
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Funding your Study Abroad Program:
Students are encouraged to explore various scholarship, bursary and award opportunties that may be available
to them. Here is a list of websites with additional information:
http://artsandscience.usask.ca/students/scholarships/
http://students.usask.ca/goabroad/planning/funding.php
http://students.usask.ca/current/paying/scholarships/
SECTION THREE: STATEMENT OF PURPOSE
Please attach a brief statement (1 page) outlining your academic and/or personal interest in this
study abroad program. How will this program benefit you personally and or academically?
SECTION FOUR: ADDITIONAL INFORMATION
ADDITIONAL INFORMATION
• ACADEMIC REFERNCE FOR STUDY ABROAD: You are required to submit one academic letter of
reference in support of your application to this program – to be submitted in confidence – to Andrea
Eccleston. An Academic Reference for Study Abroad form is available at the end of this application
form.
Please list the name and contact information for your referee:
Name: ________________________________ Department: ____________________________________
Telephone number: ____________________
E-mail: ________________________________________
•
RESUME
Please enclose your resume – a condensed version is acceptable. Include relevant information about
your education, work and volunteer experience, skills, awards, recognitions, languages, and hobbies.
•
TRANSCRIPTS
Please enclose transcripts from all post-secondary institutions you have attended – unofficial copies
are acceptable.
SECTION FIVE: DECLARATION -- PLEASE READ THE FOLLOWING BEFORE SIGNING
1. I understand that it is my responsibility to be aware of the academic and financial requirements and obligations
associated with acceptance and participation in this study abroad program;
2. I understand that I will be responsible for meeting the specified academic and financial deadlines and
obligations associated with participation in the program, including, but not limited to, course registration, tuition, all
program fees, student visa (if required), required immunization for travel abroad;
3. I understand that it is my responsibility to learn as much as possible about the risks of the venture, to weigh these risks
against the advantages, and to decide whether or not to participate;
4. I understand that I will be required to sign waiver and acknowledgment forms prior to my departure. The documents will
be provided on the International Travel Registry.
5. I understand that I will be required to attend all mandatory pre-departure orientation and preparatory sessions on travel,
immigration, health and medical issues, cultural and country-specific information, and to complete all assigned trip
safety tasks on the International Travel Registry; including the online CURIE safety course and provide details about
insurance coverage, emergency contacts, and travel plans prior to departure;
6. I understand that I will be required to remain in good academic standing and that my placement may be terminated early
if I fail to maintain minimum academic standards as defined by the University of Saskatchewan, or fail to meet the
program requirements and obligations;
7. I agree to abide by the rules and regulations of the University of Saskatchewan, the study abroad program, and the host
country, governing my academic, financial, and social/behavioral status;
8. I understand that failure to abide by these rules and regulations may result in the termination of my program participation
and that further disciplinary action may be taken by my host and home campuses;
9. I hereby certify that the information that I have provided on my application is accurate and complete in all respects and
that no relevant information has been withheld;
10. I understand that misrepresentation, falsification of documents, or withholding of requested information are serious
offences which may result in my withdrawal from this study abroad program, and, may result in prosecution under the
University’s Discipline Regulations and/or the Criminal Code of Canada.
11. I understand that the University of Saskatchewan reserves the right to make cancellations or changes in emergencies or
in the interest of the program.
Signature: ______________________________________
Date: ________________________________
Application Deadline: February 1, 2015
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Academic Reference for Study Abroad
APPLICANT:
Please complete the top section of this form and ask a professor or course instructor to complete the
reference section. It is the applicant’s responsibility to ensure that their references have been submitted
prior to the deadline date. All references are strictly confidential.
APPLICANT INFORMATION:
PROGRAM INFORMATION:
Name: ____________________________Student #: ____________
Program: ___________________________
Current Address: _______________________________________
 Spring/Summer
_____________________________________________________
 Term One
Telephone: ____________________________________________
 Term Two
Destination of Course(s):__________________________________
Email: ________________________________________________
Application Deadline date: _____________
Signature: _____________________________________________

Return to the applicant in a sealed envelope. (Sign over the seal.)
Date:______________________________
OR
 Referee to mail or fax, in confidence, to:
Andrea Eccleston, Programs Coordinator
College of Arts & Science
235 Arts, 9 Campus Drive, U of S
Saskatoon SK S7N 5A5
Fax: 306-966-8839
REFERENCE:
A study-abroad program is an academically and personally challenging program that expects students to take
advantage of the unique geographic, cultural, and academic characteristics of institutions and/or regions and to
learn from both the experiential and traditional academic methods and to synthesize these approaches. Students
are involved in challenging cross-cultural situations, both in and out of the classroom. To succeed, the applicant
must have a high degree of academic and personal motivation and the ability to adjust to people of different social
and cultural backgrounds. In making decisions on the appropriateness of a student's participation in the studyabroad program, we need to know about their motivation, adaptability, academic skills, and those personal qualities
that will give students the ability to benefit fully from the experience. While we will appreciate any observations that
will assist us in evaluating the present applicant, of special interest are qualities such as competence,
independence, assertiveness, resourcefulness, quality of performance, confidence, social skills, open-mindedness,
and integrity.
We cannot overemphasize, therefore, the value of your candid appraisal of the applicant’s chances for academic
and non-academic success in a study-abroad program, weighing both strong and weak points. We will be happy to
accept a letter in lieu of this form.
Please note: We accept students into programs on an application basis. A study abroad placement cannot
be given to a student until all of the student’s application materials are received. Since the candidate’s
application cannot be reviewed until we receive this form, please submit this reference before the indicated
deadline date to the student or to the coordinator as indicated above.
Name (print): _______________________________________________
Position or Title: ____________________________
Department: _______________________________________________
Institution: _________________________________
Email: _____________________________________________________ Telephone: ________________________________
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Applicant’s name: _________________________________________________________________
1.
How long and in what capacity have you known this student?
2.
How well do you know the applicant? (Check the most appropriate response)
 Extensive contact in a variety of settings
 Well acquainted in classroom or campus environment
 Limited contact in classroom or campus environment
 Other _______________________________________________________________________________
3.
In comparison with other students whom you have known at comparable stages of their education, please
rate the applicant in these areas.
Writing ability
Ability to express himself or herself orally
Ability in meeting assignment deadlines
Ability to cope with ambiguity
Ability to adjust to and cope with
unusual/uncomfortable situations
Ability to work with a group of peers
Class attendance
Maturity
Initiative and Motivation
Open-mindedness
Common sense and good judgment
Cooperation and Adaptability
Resourcefulness
Self-Confidence
Independence
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4.
I  would  would not
expect the student to be appropriate and considerate as a homestay participant.
5.
I  would  would not
enjoy having the student as a member of a group for which I was responsible.
Please explain:
6.
What are this student’s intellectual and/or other strengths relevant to studying abroad?
7.
What are this student’s intellectual and/or other weaknesses that might be relevant to studying abroad?
8.
Please comment on the student’s motivation for studying abroad. Does he or she have the ability and
maturity to achieve his or her goals in studying abroad?
9.
Additional comments – please feel free to make any additional comments you think might be helpful to
us in evaluating this applicant. You may attach an additional sheet if needed. Please type or print.
Signature: ________________________________________________
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Date: _______________________________