University of Georgia Study Abroad Program Application

Checklist

Instructions:

· Return complete application by February 15^th, 2007 deadline to:

Dr. Fausto O. Sarmiento. Department of Geography. 212-B Geography building. The University of Georgia. Athens, GA. 30602

· Submit all of the following materials together (except references, see below).

· Only complete applications will be considered.

Make sure the following items are included in the materials you return:

All pages of the completed and signed application (including this one).

1 official copy of your UGA transcript (Obtain from the UGA Registrar's Office)

1 official transcript from any other college you've attended.

2 reference forms or letters. (It is the applicant's responsibility to secure references by the deadline. References may be included or forwarded by the referee.)

Application fee of $500 (This fee is refundable if you are not accepted into the program. Students who withdraw from the program may have this fee refunded until March 15^th

I understand that submitting an application for a study abroad program does not guarantee acceptance into the program. Candidates must meet program requirements and be approved by the program's faculty coordinator. Participation is also subject to availability; some programs fill up early.

I further understand that the program or individual courses may be cancelled due to low enrollment or other factors and I understand that I will be informed of such a decision no later than 6 weeks before planned departure date or as soon as possible after any adverse circumstances that cause the program to be cancelled.

Student Name Signature Date

For Study Abroad Program Use Only:

Date Received Application Fee Received

Check Number Missing Items

Decision

University of Georgia Study Abroad Program Application

GEOGRAPHY FIELD STUDY IN THE AMERICAS. STUDY ABROAD IN ECUADOR

Personal and Academic Information

Social Security Number

Full Name

Preferred Name

Birth Date Age Sex: M F

Mother/guardian’s Name

Father/guardian’s Name

Are you on financial aid (including HOPE) Yes No

What types?

Your college/univ.

Are you a Georgia Resident? Yes No GPA GPA in major

Major(s)

Minor(s)

Academic Level 1^st year 2^nd year 3^rd year 4^th year Master’s Ph.D.

^{(during study abroad)}

Campus Address Phone

E-mail

Permanent Address Phone

Citizenship Passport Number

Date of Issuance Passport Agency Date of Expiration

Please list all colleges or universities previously attended:

Name Dates: From to

Degree(s) awarded Major

Name Dates: From to

Degree(s) awarded Major

Name Dates: From to

Degree(s) awarded Major

Personal Activities

Are you currently employed? yes no Occupation

If applicable, give name, address, and phone number of employer

List the primary co-curricular activities in which you are involved and in what capacity

Disciplinary and Criminal Record

Are you currently, or have you ever been, charged with, or subject to, disciplinary action for scholastic or any other type of misconduct at any educational institution?

yes no If yes, please explain
Have you been convicted of a crime other than a minor traffic offense, or are any criminal charges now pending against you? yes no

If yes, please explain

Convictions shall include: A finding of guilty by a judge or jury, a plea of guilty, or a plea of nolo contendere, irrespective of the pendency or availability of any appeal or application for collateral relief. If “Yes”, explain fully, specifying the nature of the offense(s), the date(s) it/they occurred, the name and location of the court(s) and sentence(s) imposed. Please submit court documentation if appropriate.

Course Selections*

*Courses may be cancelled due to low enrollment.

Essay

On a separate page, please write an essay expressing why you want to study abroad, what about the host country's culture interests you most, and why the qualities of this particular program support your personal, academic, and career goals.

Release and Application Signature

I hereby authorize officials at any educational institution that I have attended to release my disciplinary records (including but not limited to records maintained by the Judicial Programs and Services Office, the Registrar, the Department of Housing, and/or the Office of the Vice President for Academic Affairs) to the study abroad program director of the program to which I am applying. I fully understand that my disciplinary records may be a factor in evaluating my application.

I further acknowledge that the information provided on this application is true and accurate to the best of my knowledge. I fully understand that providing false information during the application process may be grounds for rejecting my application or grounds for dismissal from the study abroad program.

Student Signature Date

Applicants who are accepted to participate in a UGA study abroad program are required by the University of Georgia to complete and sign a student agreement and waiver which stipulates the terms and conditions of the program, student conduct regulations and a waiver of liability.

Signature of Study Abroad Advisor/Dean/Academic Advisor (for non-UGA students only)

Name Title Date

Phone E-mail

Student has completed all the necessary steps to obtain permission to study abroad from our university. Yes __ No Signature

Questionnaire

How did you first hear about this program?

poster

flyer or brochure - obtained where?

former participant

Office of International Education

campus presentation - location/presenter

References

According to the Family Educational Rights and Privacy Act of 1974, you may decide whether letters of reference written on your behalf are to be kept confidential or available for your inspection. Please choose below and indicate your choice on the reference forms.

Confidential file Open file

Please obtain two references using the following forms and either include them in your file, or have them sent directly to the study abroad program office. References from faculty or employers are preferred. References from friends, family, or neighbors are not acceptable.

Reference Form For UGA Study Abroad Programs

Please return to: Dr. Fausto O. Sarmiento. Department of Geography, University of Georgia. Athens, GA. 30602. Fax: 706-542-2388 by (Feburary 15^th, 2007)

I. This section is to be completed by the student applicant (please print or type):

Applicant's Name

Applicant's local telephone E-mail

This reference is confidential not confidential

II. This section to be completed by the referee

Name and title of referee

Phone E-mail

1. How long have you known the applicant and in what capacity?

2. Is there any reason why you would not recommend that the applicant participate in a study abroad program?

Please indicate your perceptions of the applicant's competence in the following areas:

Area Below Average Above Outstanding Inadequate

Average Average Opportunity

To Observe

Intellectual

Curiosity

Emotional

Maturity

Stress Tolerance

Ability to interact

with others

Adaptability

Cooperation

Self-motivation/

Initiative

Other remarks may be written or typed on the back of this form or on a separate sheet.

Signature of Referee Date

Please notify the student when he/she may pick up reference or forward it to the address above.

Reference Form For UGA Study Abroad Programs

Please return to: Dr. Fausto O. Sarmiento. Department of Geography, University of Georgia. Athens, GA. 30602. Fax: 706-542-2388 by (Feburary 15^th, 2007)