SW VIRGINIA INTERNATIONAL STUDY IN GERMANY May 19 – June 1, 2013 APPLICATION PACKET One Partnership Circle P. O. Box 1987 Abingdon, VA 24212Fill out this application packet in its entirety: 1. Application 2. Health Information Form 3. Assumption of Risk and Condition of Participation FormAttach to the packet: 1. Your non-refundable application fee for $250.00 (See Background Information). 2. Completed essays (See Background Information).Make arrangements to have sent to SVHEC: (Student Applicants only) 1. Copy of official transcript from your college or university. 2. Letter of recommendation form completed by your college or university.(Please use a sealed envelope with the recommender’s signature across the back.Transcript and letter of recommendation may be received after application deadline.) Completed application packet should be mailed to: George L. Hiller, J.D. Director of International and Internship Programs Southwest Virginia Higher Education Center P O Box 1987 Abingdon, VA 24212 Tel.: (276) 619-4374 Fax: (276) 619-4309 E-mail: firstname.lastname@example.org
APPLICATION DEADLINE: DECEMBER 5, 2012 BACKGROUND INFORMATION SW VIRGINIA International Study in Germany 2013The U. S. Department of Education and the Virginia Tobacco Commission have awardedthe Southwest Virginia Higher Education Center grants to support a series ofinternational business study trips to Germany for faculty and students at colleges in farSW Virginia. Dr. Amelia Harris from UVA-Wise and Mr. George Hiller from the SWVirginia Higher Ed Center are the program leaders.Please note the following: 1. Participants must be at least 18 years of age. 2. A non-refundable application fee check of $250 payable to the “SW Virginia Higher Education Center” is due with your application. However, if you are not selected for the program, your check will be promptly returned to you. 3. Participants will be responsible for reserving and paying for their own airplane tickets to/from Europe. Our travel agent will provide information for the flight and will assist participants with the reservation. We will depart on May 19th and return on June 1st . Participants may depart for Germany before May 19th and stay over in Europe after June 1st if they wish, but will need to make those arrangements themselves. Our travel agent can also assist with that. We will have a bus to pick up the group at the airport on Monday morning, May 19th. 4. All participants MUST participate in the entire program that will conclude in Berlin, Germany on Friday morning, June 1, 2013. We reserve the right to dismiss any participant from the tour who does not join in all activities. 5. There is no additional participation fee. Via our grants, we will cover: lodging/breakfast, ground transportation in Germany, admission fees, ground program, and some group dinners.
6. One hour of academic credit will be available via UVA-Wise for an additional fee. 7. You must have a passport from the US or another country that is valid until at least November 1, 2013. The U.S. Passport application fee, to be paid by you, is approximately $160. Please note the U.S. passport application process may take up to two months to complete. You should request your passport as soon as possible. (There is no visa required for travel to Germany.) 8. The SW Virginia Higher Education Center will arrange and pay for emergency health insurance coverage for each participant. 9. All selected faculty and student participants will be required to attend a pre-trip briefing session. This will be scheduled for March, 2013 and is obligatory. 10. Along with your completed application student applicants should please include two essays of approximately 200 words: a. Why is it important for SW Virginia students to learn about other cultures, including international business and technology? b. Briefly explain your current career goals including international interests.Preference for participation will be given to faculty and students from: Emory & HenryCollege, King College, University of Virginia’s College at Wise, Virginia IntermontCollege, Mountain Empire CC, Southwest Virginia CC, Virginia Highlands CC, andWytheville CC. Students at other colleges and universities who are legal residents ofSW Virginia are also encouraged to apply. The preference is for students majoring orminoring in business, economics, sciences, engineering, math, and technology as wellas faculty in those disciplines. However, faculty and students from all academicdepartments are invited to apply.
APPLICATION FORM SW VIRGINIA INTERNATIONAL BUSINESS STUDY IN GERMANY 2013 SW VIRGINIA HIGHER EDUCATION CENTER (SVHEC)________________________________________________________________A. Personal InformationLegal full name: ____________________________Preferred name: ___________________________Sex: M F Birth date: ______________Social Security Number: ________________________________Are you a U.S. citizen? Y NIf YES, do you have a U.S. Passport? Y NPassport Number: __________________ Expiration Date: ___________________If NO, country of citizenship and passport number: _____________Campus address: ____________________________ _____________________________Home address: _____________________________ _____________________________Telephone(s): _______________________(H) ____________________ (C)E-mail: ____________________________Emergency contact person(s) (name/telephone):____________________________________________________________________________________________
B. Academic InformationCollege or university where enrolled:____________________________________________________Year in school as of August 2013 _______________Major/ Intended Major: ______________________________ Current GPA: __________Minor: __________________________________________Are you in good standing judicially at your current school? Y NIf NO, please attach an explanation to this application.Have you ever been convicted of any crime, excluding minor traffic violations that did notinvolve bodily injury to others? Y NIf YES, please attach an explanation to this application.Have you ever been sanctioned by your college or university for a violation of theirstandards of conduct? Y NIf YES, please attach an explanation to this application.I have also read and understand the “Background Information” including the pre-tripmeetings requirements. Signature: __________________________ Date:_______________________________
HEALTH INFORMATION FORM SW VIRGINIA INTERNATIONAL BUSINESS STUDY IN GERMANY SW VIRGINIA HIGHER EDUCATION CENTER (SVHEC)Medical and Special Considerations Self-Disclosure:Instructions:The purpose of this form is to help SVHEC and the directors of the SW VirginiaInternational Business Study in Germany be of maximum assistance to you should theneed arise during your education abroad experience. Mild physical or psychologicaldisorders can become serious under the stresses of life while abroad. Although youhave the right not to disclose your medical conditions or special needs, we stronglyencourage you to do so. It is important that the program be made aware of any medicalor emotional problems, past or current, which might affect you in a foreign study context.Except for the directors of the International Business Study in Germany Program, theinformation provided will remain confidential and will be shared with faculty orappropriate professionals only if pertinent to your own well-being. SW VirginiaInternational Business Study in Germany directors will do their best to accommodate alldisclosed individual needs or circumstances, although sometimes this is not possible.Undisclosed needs cannot be accommodated and may in certain cases lead to studentor faculty withdrawal from the program. (You may add an additional page, if necessary.) 1. Do you have any chronic or long-term health condition? Yes____ No____ If yes, please specify below. 2. Have you ever been, or are you currently being, treated for any psychological or emotional problems? Yes_____ No_____ If yes, please specify below. 3. Do you have a learning disability documented with your home university? Yes______ No______ If yes, please specify below 4. Do you have any other disability or special needs that require accommodations? Yes______ No______ If yes, please specify below 5. Do you have any dietary restrictions? Yes______ No______ If yes, please specify below.
ASSUMPTION OF RISK and CONDITIONS OF PARTICIPATIONSW VIRGINIA INTERNATIONAL BUSINESS STUDY IN GERMANY SW VIRGINIA HIGHER EDUCATION CENTER (SVHEC) Read CAREFULLY and initial on each line indicating that you understand and agree with the specified statement.Travel Risks I realize that international travel and study, including participation in studyabroad, involves significant inherent hazards and risks, both foreseeable andunforeseeable, including travel in difficult terrain and inclement weather; inadequate orunhealthy food and water supplies; accidents or collisions involving planes, trains,buses, automobiles, or other modes of transportation; acts of terrorism, vandalism, orwar; storms, earthquakes, or other natural disasters; government restriction orregulation; theft or other criminal acts; and accident or illness in remote locations withoutaccess to appropriate medical facilities. These risks and hazards may result in seriousphysical injury, illness, death, and damage to or loss property, and I assume all suchrisk. In consideration of the Southwest Virginia Higher Education Center (SVHEC)permitting me to participate in this experience, I hereby release and covenant not to sueand forever discharge SVHEC, its Trustees, officers and employees and students fromall claims, demands, liabilities, damages, and losses arising out of, or in any way relatedto my selection of or participation in, or in any way connected with my time abroad._____I have carefully read the US Dept. of State Consular Information Sheet forGermany: http://travel.state.gov/travel/cis_pa_tw/cis/cis_1123.htmlAcademic Policies and Procedures The SW Virginia Study in Germany program is first and foremost an academicexperience. Participants are expected to participate to the fullest extent of the program(i.e., orientation, classes, group trips and activities, standards of academic work andresponsible conduct). The directors reserve the right to dismiss any participant from thetour who does not join in all the activities.Code of Conduct The program arranged by SVHEC is a supervised program and certainstandards must be observed. All participants must at all times comply with SVHEC rules,standards, and instructions for student conduct and behavior as well as any statedcodes of conduct from the host institution/agency. SVHEC reserves the right to enforceappropriate standards of conduct and specifically reserves the right to terminate theparticipation of any student for failure to maintain these standards or for any actions ofconduct which SVHEC considers to be incompatible with the interest, harmony, comfortor welfare of participants.
In particular, either possession/consumption of controlled substances (by U.S.definition, or that of any other country visited) or alcohol impairment/abuse may result inimmediate termination from the program. Participants are expected to act responsibly atall times. If any participant should have his or her participation terminated in accordancewith conditions above, then SVHEC shall have the right to require the participant toleave the program without refund of participation fees. I understand that during free time within my international experience, myabsence from my study abroad classes or group activities, and during my independenttravel, neither SVHEC nor my host staff is responsible for me and/or my actions. I understand that as an American citizen (or foreign citizen) in another country, Iwill be subject to the laws of that country. I agree to conduct myself in a manner that willcomply with host country laws and with the regulations of my host university and/orprogram. I understand that the program has the right to terminate my participation in theprogram if, in the judgment of my hosts, my conduct is unacceptable and/or disruptive.Cost and Payments I understand that I am solely responsible for all costs incurred by and related tomy voluntary participation in my international program or experience. I understand that I am solely responsible for any and all costs arising out of myown voluntary or involuntary withdrawal from my international experience prior to itscompletion, including withdrawal caused by illness or disciplinary action. I understand that I am required to have adequate health, accident, andevacuation insurance to cover myself during participation in the program, including travelbefore and after my program.Authorization and Agreement: I certify that the information on application for this international experience is true and accurate. I hereby waive my right of access to letters of reference, which may be submitted in support of my application. I understand that if any information is found to be false, my application to participate in my international experience will be terminated. I hereby grant permission for the program directors and the SVHEC administration to contact those listed as my emergency contact, and/or either of my parents, if such contact is determined to be appropriate under the circumstances. Such circumstances include, but are not limited to: illness or injury, disappearance, arrest or detention by law enforcement agencies, or dismissal from the program.
By signing this document, I hereby acknowledge that I understand andaccept the above costs and conditions of this activity. ______Signature of Participant DatePrinted Name of Participant
SW VA INTERNATIONAL STUDY IN GERMANY MAY 2013 Faculty Recommendation Form Return to: George L. Hiller, J.D. Director of International and Internship Programs Southwest Virginia Higher Education Center P.O. Box 1987 Abingdon, Virginia 24212___________________________________Full name of applicantStudent Waiver Statement: In accordance with the “Family Educational Rights and Privacy Act of 1974” itis recognized that students enrolled in this study abroad program have the right to inspect and review allmaterials in their files unless they sign the following statement: I understand my right under the provisions of PL 93-380.513 as amended 20 US Code Section 1232G et al. 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. This waiver will remain in effect until I notify, in writing, the University, at which time this document will be removed from my file and returned to the author, or until this recommendation is destroyed.__________________________________ ______________________________Signature of applicant Date INSTRUCTIONS TO THE INDIVIDUAL COMPLETING THE RECOMMENDATION FORM:The applicant is responsible for returning this form to us. Please put the completed form in a sealedenvelope and sign the back for security. Please return the recommendation to the applicant.1. How long have you known the applicant?_______________________________________________________2. In what context have you known the applicant:___________________________________________________
3. Please rank the applicant on the traits below. Circle the most appropriate ranking for each trait using thefollowing scale: (U=Unknown; 1=Poor; 2=Fair; 3=Good; 4=Excellent).Academic ability U 1 2 3 4 Able to communicate in German U 1 2 3 4Adaptability U 1 2 3 4 Intellectual curiosity U 1 2 3 4Ability to communicate U 1 2 3 4 Dedication/seriousness U 1 2 3 4Ability to cooperate U 1 2 3 4 Self-reliance U 1 2 3 4Emotional stability U 1 2 3 4 Ability to withstand stress U 1 2 3 44. What is applicant’s strongest attribute?5. What characteristic might be a liability on a study-abroad program?6. Please indicate your opinion of this individual and her/his chance of success in this study abroadprogram?7. Considering your overall evaluation of this applicant, what is your recommendation with regard toher/his acceptance to this study abroad program: Do Not Recommend Recommend with Reservation Recommend Strongly recommendName of Reference ____________________________________Title ______________________________Signature ___________________________________________ Date _____________________________Address ____________________________________________Phone ( ) ________________________E-Mail_____________________________________________ Thank you for your time and consideration of this individual.