APPLICATION FOR APPROVAL TO STUDY ABROAD
Name of Study Abroad Program:Period of Study: / Academic Year 20___-____/ Fall 20___ / Spring 20___
Name: (Last, First, M.I.)
Clark ID #:
Birthdate: (MM/DD/YYYY) / Campus Box #
Citizenship:
Clark E-Mail:
Home Address
Cell Phone
Graduating Class: / GPA
Major (1) / Major (2)
Minor (1) / Minor (2)
Concentration (1) / Concentration (2)
Faculty Advisor(1)
Faculty Advisor (2)
Do you have a passport? If yes, when does it expire? If not, have you applied for a passport? When?
Have you ever been on social or academic probation? If yes, explain.
Do you receive tuition assistance as a Clark family member? (Is a parent employed by Clark U?) / ( ) YES / ( ) NO
Do you receive Clark Financial Assistance (including scholarships and/or loans)? / ( ) YES / ( ) NO
Do you receive a Pell Grant? / ( ) YES / ( ) NO
· I understand that any violation of university academic and disciplinary policy is likely to affect my opportunity to study abroad.
· I hereby authorize the release of my academic, disciplinary and medical records, including mental health records, to the Study Abroad Office. I also authorize the Study Abroad Office to further release any of such records that they deem relevant or necessary to the study abroad agents in the country where my study abroad program occurs.
Signature: ______Date: ______
Clark University does not discriminate against qualified persons on the basis of race, color, sex, sexual orientation, religion, national origin, age as defined by law, or handicap. Clark University is an Affirmative Action/Equal Opportunity institution.