Education Abroad Application Form


Note:     indicates required fields.
PROGRAM AND DESTINATION COUNTRY
Exchange Students Please Click Here.

PARTICIPANT INFORMATION
First & Last Names (Exactly as they will appear on you passport):
Given Name Middle Name(s) Family Name

What name do you go by? 

Sex
  Year-
2016
Month-
JAN
Day-
23

Current Mailing Address:
# Street City Province
Country Postal Code

Email Address
Best Phone# to Reach You:
Cell Phone:
Have you ever been convicted to a criminal offence for which you have not been pardoned?   
May we release your name and email address to other participants in your study abroad program?   

PASSPORT
We require a copy of the information page for our file. If you don’t have a valid passport, submit this application form and provide us with a copy of the information page of your passport when you receive it.
Type of Passport:
Year-
2016
Month-
JAN
Day-
23
Are you applying for a new passport or renewing your passport?
You passport must be valid for six months past your intended date of return.

International Students:
Year-
2016
Month-
JAN
Day-
23
Year-
2016
Month-
JAN
Day-
23
 
ALL International Students must provide a Study Permit Expiry Date.

MEDICAL
Medical travel insurance is mandatory. Coverage under a provincial medical services plan (or equivalent) is also required.
Are you covered by a provincial medical plan
Medical Services Card Number: Province of Issue:
Are you covered by the Student Union health and dental plan?

EMERGENCY CONTACTS
Emergency Contacts: Relationship: Phone Number: E-Mail: Country of Residence:
1.
2.
I give VIU permission to contact or talk to my emergency contacts while abroad regarding:
Fee Payments
Program Details

Education Abroad Self-Assessment


Your health and safety are important to us. By completing this section you help us to understand any health or accommodation issues that we should take into consideration before you go abroad. This information will help us plan for any supports you may need, or anticipate any potential difficulties that you may encounter abroad. The information you provide in this section will be used as a guide and will only preculde participation if essential care is not available at the foreign site or if appropriate accommodations cannot be made by the partner institution or on the field school.

The pressures of living and studying in a foreign country are considerable. Even mild physical and mental health issues can be exacerbated by local conditions, the stress of cultural adjustment, and differences in medical practices. In some countries, sanitation and medical facilities may be inferior to those enjoyed in Canada, and medical attention may be hours or days away.

Should you develop a health problem between the time you complete this form and begin the overseas program, promptly notify the Education Abroad Manager (Jennifer.Sills@viu.ca or 250-740-6312) since your out-of-country medical insurance may no longer cover you.

Medical:
Do you have any medical conditions for which you regularly take medication or receive treatment (physical or psychological)? If yes, please describe.
(3000 of 3000) Remaining

Are you currently taking any prescribed medications? If yes please provide a list of these medications (don't report vitamins, routine meds such a birth control pills, skin creams).
(3000 of 3000) Remaining

Do you have any potentially dangerous allergies? If so, to what and how severe are they?
(3000 of 3000) Remaining

Have you recently had a major surgery or been advised to have one?
(3000 of 3000) Remaining


Access:
Do you have any physical limitations or disabilities?
(3000 of 3000) Remaining

Will your fitness level impact your ability to fully participate in the program (you may need to climb stairs, walk long distances on uneven road surfaces, carry luggage, etc.)?
(3000 of 3000) Remaining

Other factors that could impact access.
(3000 of 3000) Remaining


Other:
Are you currently registered with Disability Services at VIU or your home institution? If yes, by signing this form you are authorizing Disability services to provide information on your disability and needs to the SA Manager and field school faculty coordinator.
(3000 of 3000) Remaining

Do you have any dietary restrictions that might impact your participation in this program (you may be going to a country that may not have foods to meet your needs and VIU cannot guarantee the availability of special foods or diets)?
(3000 of 3000) Remaining

Do you have any struggles or barriers to learning that may impact your ability to access the learning outcomes associated with the program?
(3000 of 3000) Remaining




Please Read The Following Before Submitting
  1. It is my responsibility to learn as much as possible about the risks of the venture, to weigh these risks against the advantages, and to decide whether or not to participate.
  2. I certify that all statements made on this application form and the self-assessment form are true and correct. I understand that misrepresentation of this information in any material way may result in my being withdrawn from the education abroad program. For those programs where I am paying program fees to VIU, I have read and agree to the cancellation and refund procedure.
  3. I agree to abide by the rules and regulations of Vancouver Island University.
  4. The information on this form is collected under the authority of The University Act (RSBC 1996 Ch. 468). The use of this information will be in compliance with the Freedom of Information and Protection of Privacy Act. Any questions concerning the collection and use of this information should be directed to the manager at the address above.