Center for International Studies

Study Abroad - Programs
Exchange Program Application Form

Program profile:

Institution:
Term:

Applicant profile:

First name (as it will appear on your passport):
Make sure that you give us your official name, the one on your drivers license, passport, etc. If you give us a nickname, it will get printed on your plane ticket, and you could have serious problems at the airport.
Middle name:
Last name:
Date of Birth (month/day/year):
Citizenship:
Gender (for statistical purposes only):
SSN:
Current Academic Year:
Major(s):
Minor(s):
Current GPA:
Ethnic Background (for statistical purposes only):
Local Address:
City/State/Zip:
Local Phone #:
Local Cell Phone #:
Local Email:
Local Address Valid Until:
Home Address (if different from above):
City/State/Zip/Country:
Home Phone #:
Home Fax #:
Home Email:

Disciplinary Disclosure:

Have you ever been disciplined by the authorities of the University of Delaware or another academic institution or government agency for an infraction of rules, regulations, or laws? (Do not include minor traffic violations.) This includes past infractions for which sanctions have expired. Failure to answer truthfully or failure to reveal any past infraction is grounds for rejection from the program. Please provide the semester in which the infraction occurred and a brief description of the incident. Your disciplinary record is subject to official verification.

If “yes”, please explain the situation:

Health/Emergency Information:

How would you describe your general health?

Name and group or policy number of health and accident insurance that will cover you during your stay abroad (include both the name of the carrier and the policy number):

In case of emergency during your program, contact:

Contact Name:

Relationship:

Complete Address (street, city, state, zip):

Daytime/Work Phone #:

Evening Phone #:

Email:

Are you currently under the care of a doctor on a regular basis for a chronic or ongoing condition? If yes, specify below:

Do you suffer from any medicinal allergies? If yes, use the space below to briefly but specifically explain your allergy, including the names of medication(s) you must not take. State the chemical composition, not the brand name:

While abroad, will you require any medication (e.g., for allergies, diabetes, epilepsy, etc.) on a regular or periodic basis? If yes, specify below. State the chemical composition, not the brand name:

Short-Answer Questions:

What are the primary reasons for your interest in this program?

Explain how you are capable of handling the high level of independence and personal responsibility required to participate in an exchange program.

What are your main extra-curricular interests and pursuits? Which of these might you wish to continue while abroad?

What previous travel experience have you had?

If this exchange program requires instruction in a language other than English, please outline your experience and level of fluency in the language of the host country.

Have you consulted with your parent(s)/legal guardian(s) about this application?

If you answered “no” or feel that this question is not applicable to you, please explain.

Additional comments:

By submitting this form, you are affirming that all of the information you have given, and do give throughout is true, correct and complete.
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