Application to Summer Program

APPLICATION TO SUMMER PROGRAM

I. STUDENT INFORMATION

Please TYPE in the shaded areas as applicable. Non-shaded areas can be handwritten. After completion, keep a copy of your file sheet for future reference.

A. PERSONAL INFORMATION

1. Student’s Legal Name:

(as it appears in your passport) Family (Last) Name Given (First) Name Middle Name

2. Date of Birth: / 3. Gender: / Female: / Male:

Day / Month / Year

4. Place of Birth:

City State/Province Country

5. Country of Citizenship: / ______/ 6. Country of Permanent Residence: / ______
Native Language
7. Addresses / Current Address / Permanent Address
Valid from: / Until: / (If different than your current address)
Month/Year Month/Year
Street and Apartment #:
City:
State:
Country:
Postal Code:
Telephone Number:

Landline (Fixe)Cell phone (portable)

8. Email Addresses:

Preferred Email Address Alternate Email Address

9. Emergency Contact:

Name Relation

Phone Number Preferred Email Address

10. Do you have any special needs or require special services during your program (ie. dietery & religious considerations,

learning aids, facilities with handicap access, etc.) If so, please describe.

B. ACADEMIC INFORMATION

11. Name of Home University:
12. Field(s) of Study at Home Institution:
13. Class Level: / Soph. / Junior / Senior / Graduate / Doctorate
14. Cumulative GPA:
MICEFA EXCHANGE APPLICATION FOR:

Student’s Family (Last) Name, First Name

II. LANGUAGE LEVEL AND ABILITY

Language(s) / English / French / Other
Semesters of College level French

III. STUDENT CONDUCT & LIABILITY WAIVER AGREEMENT

This agreement is entered into by and between MICEFA (Mission Interuniversitaire de Coordination des Echanges Franco-Américains), hereafter called "MICEFA," and student applying for exchange, hereafter called "Student."

WHEREAS, MICEFA intends to provide services as stipulated by MICEFA in the context of a summer program in Paris, France and WHEREAS, Student desires to participate in the program under the terms and conditions hereafter set forth,

NOW, THEREFORE, MICEFA and Student agree as follows:

Student shall qualify for admission as a student for credit in their Home University by satisfying all requirements, including payment of fees.
Student shall obtain and provide all material, meet all deadlines, and otherwise comply with all participation requirements established by their Home University and MICEFA.
Student agrees to expend his or her best efforts in successfully completing the academic requirements of the courses in which Student enrolls.
It is understood that the international implications of this agreement are such that the conduct of Student during the course of the program is of utmost importance. Student, therefore, agrees to conform to standards of conduct consistent with the maintenance of a positive reputation of the MICEFA and to conform to all applicable rules, regulations and policies. Student understands and agrees that in the event the Program Director, in his or her discretion, shall determine the conduct or academic standards of Student are detrimental to the best interests of the program, the Director may terminate the participation of Student in the program. Such termination shall not diminish or otherwise affect Student’s obligation to make to MICEFA any payments that are part of the program. MICEFA in no event shall be required to refund to Student any payment made by Student to MICEFA, but may make such refunds as are consistent with Program Director’s discretion.
Student understands that there are dangers, hazards, and risks inherent in international travel, living in a foreign country, and the activities included in the university exchange program including but not limited to air, land and sea travel, dietary differences, diseases less common in the United States, differences in legal expectations and protection, building code and other safety differences, any of which could result in serious or even fatal injuries and property damage. Student agrees to assume all the risks and responsibilities surrounding student’s participation in the university exchange program, and understands and agrees that MICEFA cannot and does not assume responsibility for any such personal injuries or property damage.
Student agrees that MICEFA and each and every officer, agent and employee shall not be responsible for any injury, damage, or loss to Student or Student’s property which occurs from any cause beyond the control of MICEFA, or which does not occur from the sole negligence of MICEFA.
Student further agrees to hold harmless, defend and indemnify MICEFA and its employees from any and all claims, injuries, damages, losses, causes of action, and demands, and all costs and expenses incurred in connection therewith (hereafter in this paragraph 7 collectively referred to as “liability”) resulting from or in any manner arising out of, or in connection with any negligence on the part of Student, his or her agents, or employees, in the performance of this agreement, irrespective of whether such liability is also due to any negligence on the part of MICEFA.
Student agrees to comply fully with the rules of MICEFA, its agents, and/or employees and agrees that MICEFA reserves the right to enforce its standard of conduct and collect on any financial holds incurred by the student as indicated on Student’s record and that, should Student fail to comply, MICEFA has the right to withhold any and all academic documentation (i.e. Student’s transcript), and/or to terminate Student’s participation in the program.
Students agree to comply fully with the same laws and regulations that govern the host’s country citizens and any other laws that are applicable to the students as a foreign citizen in the host country. As such, the following are prohibited:

The following are prohibited:

Violence against others. This is defined as striking or doing any physical harm to another
Verbal abuse of students or others
Theft, damage, or vandalism to property of host lodging
Disorderly, disruptive, threatening, or intimidating conduct, gestures or actions
Criminal behavior or violation of local laws
Self-endangerment, including involvement in activities or behaviors that could result in personal harm, including, but not limited to, frequenting dangerous places, association with criminals, repeated intoxication, etc…
Alcohol or drug policy violation
Alcohol may be consumed, within reasonable limits, by students who are of legal age in the host country.

Students who choose to consume alcohol do so with the knowledge that they remain responsible for their actions at all times and are expected to drink responsibly. We prohibit the illegal distribution of alcohol to students who are not of legal drinking age. Further, excessive and irresponsible drinking leading to intoxication and behavior that interferes with the program or rights of others is subject to immediate disciplinary action, and may result in dismissal from host country. Note that the study abroad insurance does not cover any injuries that occur while you are under the influence of alcohol, intoxicants, or any drug not prescribed by a physician.

Students are prohibited from selling, using, or possessing any drugs that are considered by the host country law to be illicit or illegal. Students are cautioned that the possession of drugs is often dealt with harshly by host country law enforcement.

By signing below, MICEFA and Student manifest their agreement to these terms and conditions.

Student Signature: / Date:

IV. STUDENT CONDUCT OF CONDUCT AGREEMENT:

Students who participate in MICEFA’s Summer Program are representatives of MICEFA and their home country for the duration of their time on the program. Students are expected to conduct themselves appropriately and respectfully at all times. Students participating in the Summer Program are expected to abide by the Student Code of Conduct of MICEFA and their home institution along with the laws and customs that govern the host country. Students are legally subject to the same laws and regulations that govern the host’s country citizens and any other laws that are applicable to the students as a foreign citizen in the host country.

The following are prohibited:

Violence against others. This is defined as striking or doing any physical harm to another
Verbal abuse of students or others
Theft, damage, or vandalism to property of host lodging
Disorderly, disruptive, threatening, or intimidating conduct, gestures or actions
Criminal behavior or violation of local laws
Self-endangerment, including involvement in activities or behaviors that could result in personal harm, including, but not limited to, frequenting dangerous places, association with criminals, repeated intoxication, etc…
Alcohol or drug policy violation
Alcohol may be consumed, within reasonable limits, by students who are of legal age in the host country.

Students are prohibited from selling, using, or possessing any drugs that are considered by the host country law to be illicit or illegal. Students are cautioned that the possession of drugs is often dealt with harshly by host country law enforcement.

As a participant in the MICEFA exchange program, I ______hereby agree to the aforementioned statements.

Paris, ______, 20_____

Signature: ______

MICEFA EXCHANGE APPLICATION FOR:

Student’s Family (Last) Name, First Name

IV. SUBMISSION OF APPLICATION

Submit the original application plus the following materials to the Study Abroad office at your home institution:

 Copy of the page of your passport showing your photo and full legal name;

 4 ID size photos;

 2 letters of recommendation;

 Official transcripts of all higher education institutions/ university studies;

 Signature on Code of Conduct agreement (page 2);

 Proof of International Health Insurance coverage.

Application and supporting documents may be submitted electronically to MICEFA.

V. HOME INSTITUTION ENDORSEMENT (to be completed by your home university)

I have verified that the student is submitting a completed application, which includes the documents listed in Section IV. After reviewing the student’s application, I recommend the student’s participation in this exchange.

Printed Name: / Title of Position:
Signature: / Date:

Day / Month / Year

[November 2011, original application design courtesy of California State University System]