MiddlesexUniversityStudentExchange

RegistrationofInterestFormUG Students

IMPORTANT NOTICE: Before you complete a Registration of Interest Form:

  1. Ask your Programme Leader for advice on your exchange plans and how they can best fit into your programme.
  2. You will need them to sign this form to show that they are aware of your interest and give permission for you to go on exchange for the period determined.
  3. Once you have completed this form, scan and e-mail it to .
  4. Your exchange is then conditional on you providing a Learning Agreement showing full details of the modules you would like to undertake while on exchange.
  5. With very few exceptions (e.g. Nursing), it is not possible for students to go on a study exchange during their final year due to university regulations and degrees*.

*Please refer to page 6 of the University Regulations for further information.

For more information about grants and application procedures, please see our website at UniHub/Your employment/Student exchange.

PERSONAL DATA:

Middlesex University Student ID: |M00______|

Forename(s): |______| Surname: |______|

Middlesex Email: || Personal Email: |______|

Mobile number: |______| Passport Nationality: |______|

MIDDLESEX UNIVERSITY STUDIES:

School (e.g. Business, Health and Education):|______|

Degree Programme (e.g. BA Honours Film):|______|

PLANNED OVERSEAS STUDIES:

Academic Year you will be on exchange:□ 2017/2018□ 2018/2019

Term you plan to be abroad:□ Term 1□ Term 2□ Full Year

Year of Study during exchange: □2nd year of a 3-yearprogramme□3rdyear of a 4-yearprogramme

Will your exchange be in the final year of your degree (see above mention)?□ Yes□ No

Have you done Erasmus Exchange before? □ Yes□ No

CHOICE OF HOST UNIVERSITY (e.g. University of Valencia, Spain):*

1stChoice of University:|______|

2nd Choice of University:|______|

3rd Choice of University:|______|

*Please make a minimum of two choices.

LANGUAGE

Would you prefer to study in English? □ Yes□ No

List the languages you can read and write fluently in: |______|

Would you be interested in joining our ‘tandem’ language scheme; learn a new language and help others learn yours? □ Yes □ No

Additional information

Personal statement
The value of your exchange study visit towards your degree (not more than 300 words)
Additional information
(Special needs, financial hardship, extra-curricular engagement, community involvement, volunteering, Student Union & Societies, etc.)

BUDDY UP

Would you like to take part in our Mentor Scheme and be assigned a Student Mentor who has been on exchange and can support you in your preparation? □ Yes □ No

Would you like to join the ‘Erasmus+ International Society’ and exchange with students from all over the world who may be able to advise you onmany ‘go abroad’ aspects? □ Yes □ No

DISABILITY

Do you currently receive support from the University’s Disability Service? □ Yes□ No

More information at:

Are you happy for the Exchanges Team to discuss this with the Disability Service? □ Yes□ No

SUPPORT OF REGISTRATION OF INTEREST

I confirm that this student is eligible for a student exchange for the period specified. I acknowledge that my approval is conditional on the student completing a Learning Agreement showing full details of the modules they would like to undertake while on exchange at a later date.

Programme Leader

Signature:|______|

Name:|______|

Date:|______|

______

Registration of Interest forms without your Programme Leader’s signature cannot be accepted.

Where have you heard of the Middlesex Exchange Programme?

□ Programme Leader□ E-mail

□UniHub website□facebook

□UniHub Announcement□ Go Abroad Week

□ Friends□Other, please specify |______|

Student Exchanges Office, Middlesex University, Hendon Campus, The Burroughs, London NW4 4BT, UK

Phone: 44 (0)20 8411 5962 Email: