Michael Shaughnessy, Ph.D.
Washington and JeffersonCollege
60 South Lincoln St.
Washington, PA15301 USA
Phone: 724-223-6170
1-888-926-3529
Fax: 724-223-5271
Email:
September 7, 2006
Enclosed please find an application form and one letter-of-reference form for the W&J College Semester in Cologne (PCIC) program.
1.Please fill out the application form (typed, printed out, and signed) and return toDr. Michael ShaughnessybyWednesday, March 1,2007. Early Applications may receive pre-aproval.
2. Print out and sign the waiver for the letter of reference. The letter of reference should be from someone who is familiar with your academic work and who knows you well enough personally to provide a character reference. Please ask your referee to send the letter of reference to Dr. Michael Shaughnessy by March 1, 2007.
As soon as we have received and reviewed your application and letter of reference, we shall contact you in order to schedule a brief interview with the selection committee. Once you have been accepted into the program, we will schedule an orientation meeting to provide you with additional information about Cologne and to help you complete the various forms necessary for studying abroad.
We look forward to working with you throughout the application process and would be happy to answer any additional questions you may have.
Sincerely,
Michael Shaughnessy
Dr. Michael Shaughnessy
W&J PCIC Director
60 South Lincoln St.
Washington, PA15301
(724) 223-6170
W&J COLLEGE SEMESTER IN COLOGNE
CONFIDENTIAL REFERENCE
Return fill out, print out, sign and give to referee.
Please have the referee return completed recommendation form to:
Dr. Michael Shaughnessy
W&J PCIC Director
Washington & JeffersonCollege
60 South Lincoln St.
Washington, PA15301
______
Name of Applicant
TO THE STUDENT: Student Waiver Statement: The "Family Educational Rights and Privacy Act of 1974 (Buckley Amendment)" provides that 1) eligible students will have access to inspect and review their educational records and also 2) provides and protects the rights of a student to privacy by limiting access to the educational record without express written consent.
In accordance with the "Family Educational Rights and Privacy Act of 1974," W&JCollege recognizes that students enrolled in its national and international study programs have the right to inspect and review all materials in their files unless they sign the following statement:
I understand my right under the provisions of PL 93-380.513 to inspect letters of recommendation on my behalf. In order to encourage the authors of letters about me to write with candor, I have elected not to exercise my rights under the aforesaid statute and affirm that I shall not do so in the future.
______
Signature of applicantDate
TO THE REFERRER: The student named above is an applicant to the W&J College Semester in Cologne program. The program combines a full schedule of academic work with related excursions and a home stay with a local family for the length of the program.
To benefit from this experience, a student must be highly motivated, emotionally mature, and able to adapt easily to people with different social cultural backgrounds. Therefore, we will appreciate your thoughtful and candid appraisal of this applicant. Your remarks will be seen by faculty and staff specifically responsible for counseling the student regarding this program. If the student has signed the release above, your comments will not be available to the student.
Please mail this form to the address shown above in the envelope furnished by the applicant. We appreciate your cooperation.
______
Your name (please print or type) Your complete mailing address
______
Your occupation Your signature
______
Daytime telephone number Date
CONTINUED ON NEXT PAGE- Reference form 1 of 2
Use the following scale:
A = top 10% B = top 30% C = top 70% D - Bottom 30% E = bottom 10% X = no opinion
Circle one letter below for each:Comments
Intellectually curiousA B C D E X______
Emotionally matureA B C D E X______
Socially matureA B C D E X______
Self-reliantA B C D E X______
Self-motivatedA B C D E X______
PerceptiveA B C D E X______
Self-assuredA B C D E X______
AdaptableA B C D E X______
CooperativeA B C D E X______
PoisedA B C D E X______
Well-manneredA B C D E X______
ArticulateA B C D E X______
In what capacity have you known the applicant, and for how long?
______
______
Would you enjoy having this student as a member of your family for an extendedperiod of time?
______
If I were directing this program, I would be happy to have this student participate:
Yes _____ No _____
Additional Comments:______
______
______
(Continue on additional page if necessary)- Reference form 2 of 2
W&J COLLEGE SEMESTER IN COLOGNE
Student Application Form (Please Type)
___ Male
___ Female______
Last NameFirstMiddleCitizenship
______
Birth datePlace of birth (city, state)Social Security Number
______
Area Code and Phone No.Home Mailing Address (Street, No., City, State, Zip)
______
Area Code and Phone No.Campus Mailing Address (Street, No., City, State,Zip)
It is imperative to keep the AHA office and W&JCollege advised of your current address.
College GPA ______Major ______Major GPA______
At the beginning of the program in Cologne I will besoph ______junior ______senior ______
______
Legal name of father (if living), address and daytime telephone number
______
Legal name of mother (if living), address and daytime telephone number
______
Legal name of guardian (if other than parents), and address
List all W&J German classes and semester taken you will have completed by May:
Course / Semester / Course / Semester / Course / SemesterList other courses in German or other languages that you have taken elsewhere:
To the best of my knowledge, the information furnished by me on this form is complete and accurate. By signing I also affirm that I have read the W&J PCIC web page outlining courses, dates, and financial matters.
Signature ______
Date ______
continued on next page
Write a short essay discussing what you hope to accomplish during your stay abroad and how you hope to incorporate this experience into further academic or career plans. Be explicit and self-critical as to what you perceive as your particular strengths and weaknesses and how they might affect your plans and performance abroad.