College of Nursing
Student Application/Agreement for International Experience

Application must be submitted electronically by Noon, February 21, 2008. Clinical evaluations must be turned in by Noon, February 21, 2008.

* Indicates required field.

I am applying for:

Name*
UC Student ID Number*
Email Address*
Local Address*

City
State
Zip
Local Phone Number* (include area code)
Summer Address
 
City
State
Zip
Summer Phone Number (include area code)
GPA as of 01/01/08*
Current Student Status*

I am taking courses at
Have you previously taken a course(s) in Spanish?*



Have you previously taken a course(s) in Swahili?*



If YES, what and where?
If YES, rate your language ability.
Do you have a current passport? Yes
No
Expiration date
Health Status*

Do you have any chronic health conditions including those currently not under medical treatment?*
Yes
No

Essay* State what you expect to gain from the international experience you have selected. If you are choosing two experiences, you may combine your answer, or write separate statements. Be sure to identify the country in each statement.

Agreement
I understand that I must meet the following conditions to be included in the clinical groups traveling to Honduras during academic year 2007-08.

  1. able to walk two miles over rough, uneven, mountainous terrain carrying two liters of water, a change of clothes and other personal items,
  2. maintain a GPA of 2.8 Honduras/3.0 Tanzania (college and university),
  3. meet all prerequisites for Community as Partner and Ambulatory Care,
  4. meet all financial obligations as set by Director of Center for International Affairs, no extensions or refunds permitted,
  5. complete an application packet including:
    • online application, must be submitted electronically by Noon, February 21, 2008,
    • submit copies of both Foundations of Nursing and Care of the Adult clinical evaluations to Liz Karle, 426 Procter, or Claudia Mitchell, Clermont College, by Noon, February 21, 2008,
    • submit copies of evaluations from all other clinical courses within two weeks of completion of the course to Liz Karle, 426 Procter, or Claudia Mitchell, Clermont College,
  6. all students will be interviewed on Monday, February 25, 2008, time and location will be sent upon receipt of a completed application packet,
  7. obtain a passport, necessary visas and immunizations,
  8. attend all meetings and scheduled packing days,
  9. keep all application information current (via email),
  10. complete all course work in the quarter.

All information provided on this application form is accurate and correct. Failure to provide accurate answers and meet the terms of the agreement will result in expulsion from the program. You will return home at your own expense and a notation will be placed on your student record.
Signature (type full name)*
Date* mm/dd/yyyy