Print Form
Student Participants
(Please attach photo of yourself with face approx. 1” long; may be any type of picture.)
International Education Bio-Data Form for International Field Experience
International Education 1024 Campus Delivery Fort Collins, CO 80523-1024 Tel.(970) 491-5917 Fax (970) 491-5501 http://www.international.colostate.edu/
[email protected]
Personal Information (Print Clearly)
Academic Information
CSUID:
Class Standing:
Name: First
MI
Date of Birth:
Last
/ Month
Undergraduate Freshman Junior Masters Ph.D.
Sophomore Senior
/ Day
Year
Expected Graduation Date: MO
Marital Status: Single
Married
Other
Major:
Gender:
Male
Female
Minor:
Ethnicity: Mark all that apply (disclosure is voluntary and will not be used in a
YR
CSU Program Information
discriminatory manner).
American Indian or Alaska Native White, not of Hispanic origin Asian Black, African American, not of Hispanic origin Hispanic Native Hawaiian or Other Pacific Islander I do not wish to provide this information
Sponsoring Department: Host Country: Host City(ies): Dates of Program From:
Country of Citizenship:
To:
International Student ID Card Information
Passport Number:
*Remember to activate your card online to receive your benefits*
Date Issued:
ISIC Number:
Expiration Date: _____________________
ISIC Expiration Date:
Local Home Address:
Health Considerations
Perma
Please read and initial the following statement: The stress of travel and adjusting to a new culture can exacerbate physical or psychological conditions that may be under control at home. If you are currently receiving treatment, or have received treatment in the past, it is important that you share this information with your program advisor and that you meet with your physician or counselor to discuss how international work and travel could affect your medical condition. You may consult your personal physician, the County Health Dept. travel clinic, or Hartshorn Health Center for your travel consultation.
Permanent Home Address:
Cell/Local Phone: ______________________________________ Email: ________________________________________________ Important! You are responsible for notifying International Education in writing within 10-days of any change in address, phone or email (
[email protected]).
I understand that I am responsible for consulting my physician and getting all necessary immunizations and staying on medications recommended for my travel abroad.
Initials: Continue on next page…
Page 1 of 2
Releases: Please Complete and Sign
Emergency Contact Information 1:
Photo release Occasionally IFE participants may be photographed in program activities for use in International Education documentation and marketing. Photographs may be used in newsletters, newspapers, on web sites and in other marketing and impact reports. May we take your picture for program documentation and marketing purposes?
�Yes �No
Initials
Contact Name: Relationship to you: Address: Home Phone: Work or Cell Phone:
FERPA Release (Family Educational Rights and Privacy Act)
E-Mail:
If you wish for the Office of International Programs to be able to discuss any of the topics listed below with other designated individuals, you must provide permission for us to do so in writing.
Emergency Contact Information 2:
I give my consent to the Office of International Programs at Colorado State University to release the following personally identifiable information from my education record to the person(s) listed below, for the purpose of keeping these person(s) advised of my health, program, and/or safety while I am abroad.
Relationship to you:
(Initial all that apply):
Home Phone:
Contact Name:
Address:
Work or Cell Phone:
Health information in the event that the Office of International Programs is notified of a serious physical or mental health condition or emergency.
E-Mail:
Background Check
Information in the event of a legal and/or disciplinary situation abroad.
Your participation in the program abroad may require a legal background clearance. The Colorado State University Police Department will perform or refer you to an organization that will do a background check for a fee, if required. As a participant, you will be responsible for paying this fee.
Information regarding your program abroad. Do Not release any information Name
Relationship
Phone Number
1.
If you are a CSU student, complete this for the period of time since you have enrolled at CSU:
2.
Have you been convicted of a misdemeanor?
yes no
3.
Have you been convicted of a felony?
yes no
This consent will remain in effect for three years from the date of signature unless I provide International Programs with a written revocation of this consent.
Have you been on probation or done court ordered community service? yes no
Required Signature
Are any disciplinary actions pending at CSU?
If you have answered yes to any of these questions, please attach a letter of explanation in a sealed envelope, marked confidential, with your biodata. This will be kept confidential.
Date
Agreement: I certify that the information submitted on this form as given above is true and complete. I understand that as a participant in the program abroad I shall be subject to certain rules and requirements of this University and of cooperating organizations, which I agree to fulfill in all respects, subject to immediate dismissal from the program if I do not do so. I agree to assume financial responsibility for the program fees and for my own welfare while abroad. I understand that the International Education reserves the right to cancel, alter or amend any part of any program or to increase charges should circumstances make these actions advisable or necessary.
Signature: I am participating in this program voluntarily, and I agree to abide by all rules and regulations that pertain to students and/or employees of Colorado State University, as described in the CSU Student Conduct Code http://www.studentaffairs.colostate.edu/policies.aspx and to follow instructions and guidelines from the group leader(s)for the duration of the program.
Signature Signature
yes no
Date Page 2 of 2
Date
