From Faculty-Led Program

NOTIFICATION OF TERMINATION

FROM FACULTY-LED PROGRAM

A printable and fillable version of this form is available online at

Please complete this form for all incidents that occur during a Missouri S&T faculty-led short-term study abroad programs. Send a photo or scanned copy of the form by email to or by fax to (573) 341-6031 within 48 hours of student signature.

Student name and ID number: ______

Date and location of incident:______

Study abroad program: ______

SUMMARY OF VIOLATION

Initial incident report should contain more detailed information.

CHECK THE APPROPRIATE BOX

☐ After having received one or more verbal and/or written warning(s) on ______(mm/dd/yyyy) describing previous violation(s) of the rules and regulations for Missouri S&T students abroad, the above-named student has not desisted from continuing to violate the rules and regulations, nor has the student fulfilled the required expected behavior conditions as specific on the written warning form. For this reason, the student in question has been terminated from the program.

☐The seriousness of the violation is such that further participation by the above-named student would be to the detriment of the program and its participants either by impacting health and safety of the individual or other participants in the program or causing detriment to the best interest and welfare of the program and Missouri S&T. For this reason, the student in question has been terminated from the program.

TO BE COMPLETED BY STUDENT

I understand that, due to the violation of the rules and regulations for the Missouri S&T students abroad, I have been terminated from the above-named study abroad program. Termination shall not diminish or otherwise affect my obligation to make any and all payments to Missouri S&T. I understand that I will receive a grade of “F” in all coursework in progress; in addition, I will not be entitled to refund of fees, may be required to reimburse Missouri S&T for financial aid received and am responsible for all non-recoverable costs incurred by the host institution or Missouri S&T, as well as personal financial obligations. I understand that the conduct that led to my termination from this program may also lead to further sanctions upon returning to Missouri S&T.

I agree to absent myself from all premises used by the study abroad program within 48 hours and return to the United States.

Student’s signature:______Date:______

Program director’s signature: ______Date:______

Program director’s signature: ______Date: ______

Emergency contact information for International Affairs / Study Abroad: Last Updated: December 11, 2018

During office hours: (573) 341-6237 or (573) 341-6015 or (573) 341-6425 Email:

Outside of office hours: (573) 458-9049 (Google voice number that rings to staff cell phones) or (573) 341-4300 University Police