Study Abroad Participant Eligibility

The ideal candidate is an LCC student, faculty, staff, or alumni in good standing with the school. On certain trips, community members are allowed to participate. LCC considers international travel to be an essential aspect of being well-educated in the 21st century, and we seek participants who understand the importance of travel abroad.

TRAVEL DETAILS

The travel fees will cover the cost of the education abroad program. No per diem or mileage will be covered. The participant will be responsible for his/her own passport. The participant is responsible for some meals dependent on the travel program. The participant is responsible for any baggage fees associated with flying. The participant should have some funds with them on the travel for incidentals and personal interests.

CONDITIONS OF PARTICIPATION

  1. Participant must be a current LCC student, faculty, staff, or alumni member in good standing with the college.
  2. The participant must be in good physical health, be able to walk several miles and carry his or her own

luggage. Medical insurance is required prior to departure. Participants will be asked to complete a health form, which must be submitted with this application.

  1. The participant must be a U.S. citizen, with a passport valid at least 6 months after the return date of the chosen program. If you do not currently have a passport, you must apply for one immediately upon acceptance to the trip: passports.state.gov
  2. The participant is required to read all materials provided by LCC in preparation or follow up to the education abroad program and will be required to take part in all the scheduled group activities while traveling.
  3. The participant must assume responsibility for obtaining and bearing the costs of obtaining passports, recommended vaccinations, and any other travel-related documents. LCC will supply helpful information to assist with the necessary documentation.
  4. The participant must submit an electronic scanned copy or photocopy of the first page of their passport by February 5, 2018.
  5. The participant must read and type his or her name for each section of this form. Your typed name will be confirmation that you have read and provided the correct information to the best of your knowledge for each section.

PARTICIPANT INFORMATION

Full NameClick here to enter text.

(Exactly as it appears on your passport)

Preferred NameClick here to enter text.

Street AddressClick here to enter text.

City Click here to enter text.State Click here to enter text.

Zip Code Click here to enter text.Home Phone Click here to enter text.Cell Phone Click here to enter text.

PARTICIPANT STATUS

☐ Student☐ Faculty/Staff ☐ Alumni ☐ Other

PROGRAM OF STUDY OPTION

Program of study Click here to enter text.LCC Student ID Number Click here to enter text.

PASSPORT NUMBER

Passport Number Click here to enter text.Passport Expiration Date Click here to enter text.

(If you do not have a passport yet, you must bring a copy of the first page of your passport to the LCC Student Services office by February 5, 2018.)

Date of Birth (MM/DD/YYYY) Click here to enter text.

EMERGENCY CONTACT ONE

(Please provide contact information for your first emergency contact.)

First and Last Name Click here to enter text.

Street Address Click here to enter text.

City Click here to enter text.State Click here to enter text.

Zip Code Click here to enter text.Home Phone Click here to enter text.Cell Phone Click here to enter text.

Email Click here to enter text.Relationship to YouClick here to enter text.

EMERGENCY CONTACT TWO

(Please provide contact information for your second emergency contact.)

First and Last Name Click here to enter text.

Street Address Click here to enter text.

City Click here to enter text.State Click here to enter text.

Zip Code Click here to enter text.Home Phone Click here to enter text.Cell Phone Click here to enter text.

Email Click here to enter text. Relationship to YouClick here to enter text.

EMERGENCY CONTACT COMMUNICATION FORM PRIMARY CONTACT

I authorize the Student Services Office of International Programs or the Program Leader to communicate with the emergency contacts listed in the previous sections regarding all issues involving my education abroad experience. I expressly waive any privacy rights I may otherwise have under FERPA and HIPAA. Such contact may occur before, during, or after the program.

☐Yes

☐No, I understand that if I do not provide this information LCC may be unable to help me.

Full NameClick here to enter text.Date Click here to enter text.

CONFIDENTIAL INFORMATION WAIVER FORM

By typing my name below, I request that LCC have access to any relevant information in my student file, employee file, and student financial account. This permission is given with the understanding that all such information is completely confidential, is to be used only in order to make determinations of importance to the placing and support of the participant going abroad, and that the information is to be requested only when necessary.

Full NameClick here to enter text. Date Click here to enter text.

Please answer the following questions.

  1. What do you expect to learn and experience from this trip?
  1. What concerns do you have about the trip?
  1. What benefit do you expect from this experience either academically, professionally, and/or personally?
  1. Do you have any medical conditions relevant to demanding travel in remote areas (including, but not limited to, diabetes, asthma, high blood pressure, allergies, etc...)? Or any medical conditions that the trip coordinator should know of for your health and safety? (Please explain. This information will be kept confidential.)

EDUCATION ABROAD PROGRAM REFUND AND CANCELLATION POLICY

(Please read the policy below fully and carefully.)

REFUND POLICY
Lenoir Community College (LCC) must pay charges to various international institutions and organizations to hold places for education abroad participants. Other program expenses are incurred well before the program begins based on the number of participants in the program. Therefore, it is sometimes impossible for payments to be refunded in full if a participant chooses to withdraw from a program. All withdrawals must be made in writing and submitted to the International Programs within the Student Services Office.

The following policies apply to LCC programs.

Please note that only in exceptional circumstances can these policies be modified.

  • Any application fee charged by a program is not refundable, unless the participant's application is rejected.
  • If a participant voluntarily withdraws from an education abroad program after application to the program but prior to the start date of the program, the participant will be refunded the program cost, excluding application fee and any portion of the program cost which is unrecoverable* (pre-paid meals, pre-paid room reservation deposits, etc.). Even if the participant has not yet paid the full program balance, he or she is obligated to pay LCC for any unrecoverable expenses incurred on the participant's behalf. This may require the participant to pay part of the program cost to LCC, even if he or she does not attend the program. It is, therefore, in the participant's best interest to notify the LCC Student Services Office immediately when making a decision to withdraw.
  • If a participant voluntarily withdraws from a study abroad program after the program officially begins, no money will be refunded.
  • If a participant is required to withdraw from a study program for any reason after the program officially begins, no money will be refunded.
  • Participants in any program who choose NOT to participate in a program activity, either mandatory or non-mandatory, (such as a field trip, excursion, cultural event, etc.) will NOT be refunded any portion of the program cost.
  • Unrecoverable costs may include expenses for both individual and group services. Individual expenses are items such as airline tickets or pre-paid room reservations. Group expenses may include bus rentals or payment to guides. For example, if the program budget is based on a minimum of 15 participants, and the 15th participant withdraws, then a portion of the cost for some group services also becomes an unrecoverable loss.

CANCELLATION POLICY

  • The general policy is that we will cancel any LCC sponsored program in a location where the U.S. State Department has issued a travel warning or where LCC deems the location to be unsafe.
  • Should a program cancellation become necessary for safety reasons prior to participant’s departure, every effort will be made to refund recoverable costs. The time of program cancellation will determine the actual recoverable costs. The closer the program is to the start date; the less recoverable costs will be available. For example, 3 months before a program starts, funds have usually already been paid to many hotels for deposits on housing. These deposits would be considered non-recoverable.
  • Should a program cancellation become necessary for safety reasons after participants have arrived overseas, our refund policy is that every effort will be made to refund recoverable costs to the participants. Because full refunds are often not possible, participants may wish to consider purchasing trip cancellation insurance which can be obtained through many travel agents or insurance companies. This must be purchased from an insurance provider within 14 days of when the initial program deposit is paid.

I have been furnished a copy of the refund and cancellation policies, have read it, and indicate I agree to it by typing my name below.

Full NameClick here to enter text. Date Click here to enter text.

CONDUCT DISCLOSURE

As a representative of LCC, the participant will conduct themselves in a professional manner while abroad.

LCC Student Services will review all student conduct records.

I certify, to the best of my knowledge, I have NOT been referred to the Office of Student Conduct for violating the Student Code of Conduct Policy.

☐Yes

☐No, I have been referred to the office.

Please describe the reason why you were referred to the Office of Student Conduct and the outcome of your referral. Click here to enter text.

LCC STUDENT SERVICES HEALTH FORM

IMPORTANT: Because an education abroad experience can be both physically and emotionally demanding, we ask that you provide a candid evaluation of your health. A certain amount of stress due to culture shock or the change in living conditions and facilities is a normal part of the education abroad experience. However, in some cases, such stress may aggravate disabilities or illnesses that you have under control at home.

With this form, we hope to create an awareness of any health issues that you should take into consideration before going abroad. This information will be used primarily to guide us in making appropriate arrangements for you as a participant in LCC education abroad programs. The information may also be forwarded to contacts in the host country and/or your Program Leader.

Full Name Click here to enter text. LCC Student ID Number Click here to enter text.

AgeClick here to enter text.Height (ft’in”)Click here to enter text. Weight (lbs)Click here to enter text. Date of Birth (MM/DD/YYYY)Click here to enter text.

Gender ☐Female☐Male ☐ Prefer not to say

Blood Type☐O+☐O-☐A+☐A- ☐B+☐B-☐AB+ ☐AB-☐Do not know

CHECK YES OR NO FOR THE FOLLOWING QUESTIONS

(Please add additional information if needed in the explanation sections.)

  1. Are you in generally good physical condition?

☐Yes

☐No(If no, please explain.)Click here to enter text.

  1. Have you been treated or are you currently being treated for any psychological or emotional problems?

☐Yes(If yes, please explain.)Click here to enter text.

☐No

  1. Do you have allergies?

☐ Yes(If yes, please detail all your allergies.)Click here to enter text.

☐No

  1. Are you taking any medications?

☐ Yes (If yes, please identify the medication and the condition for which it is prescribed.) Click here to enter text.

☐ No

  1. Have you had any major injuries, diseases, or ailments in the past five years?

☐Yes (If yes, please explain.) Click here to enter text.

☐No

  1. Do you have any pre-existing conditions?

☐Yes (If yes, please explain.) Click here to enter text.

☐No

  1. Are you a vegetarian or on a restricted diet?

☐Yes (If yes, please explain.) Click here to enter text.

☐No

  1. The ADA does not apply outside the United States and LCC is not legally required to provide accommodations to participants participating in education abroad programs. Nevertheless, do you have a disability that requires special facilities, equipment or conditions to permit your participation in this study abroad program and about which the LCC should be aware? (If yes, please identify your disability and particular needs, understanding that LCC may not provide an accommodation.)

☐Yes (If yes, please explain.) Click here to enter text.

☐No

  1. Is there any additional information--medical, physical, emotional, educational-- that would be helpful for LCC to be aware of during your education abroad experience?

☐Yes (If yes, please explain.) Click here to enter text.

☐No

CERTIFICATION STATEMENT

I certify that all responses made on this form are true and accurate, and I will notify the LCC Student Services for International Programs or my Program Leader hereafter of any relevant changes that may occur prior to or during my education abroad program. Failure to disclose information can result in removal or disqualification from LCC education abroad programs.

I agree that if I am injured or become ill, LCC or its agents may secure hospitalization and/or medical treatment for me and I agree to pay all expenses related thereto. I further agree that, if I become incapacitated due to illness or accident, I authorize the release of my health information to LCC or its agents so that they may provide me with needed assistance. I further authorize LCC or its agents to release my health information to other persons who may need this information to assist me or to assist others in the program.

I agree to release and hold harmless LCC and their employees and agents from any claims arising out of their use or disclosure of my health information and the provision of medical care in my host country.

I understand and agree that this form may be released to my host institution or the education abroad program leader. I also understand and agree that LCC is not responsible for any decisions made overseas, based upon information received from any source about my physical condition.

I understand as a representative of LCC Faculty/Staff, the scholarship participant will conduct themselves in a professional manner while abroad.

Please sign and return to Student Services in the Administration Building.

Print Full NameClick here to enter text.

Signature ______Date Click here to enter a date.