DATE OF BIRTH / / PLACE OF BIRTH month/day/year COUNTRY OF CITIZENSHIP IF YOU HOLD A U.S. PASSPORT, LIST ITS EXPIRATION DATE

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1 APPLICATION FORM FR127j Department of French and Italian, Colby College This 2-page application must be submitted by SEPT 26, 2016 to Ms. Wood in Lovejoy 317. This is the only document due by that date. Please print neatly. NAME last first middle COLBY ID # SOCIAL SECURITY # CLASS YEAR MAJOR(S) DATE OF BIRTH / / PLACE OF BIRTH month/day/year COUNTRY OF CITIZENSHIP IF YOU HOLD A U.S. PASSPORT, LIST ITS EXPIRATION DATE HOME ADDRESS HOME PHONE # COLBY MAILING ADDRESS COLBY PHONE # ADDRESS FATHER S NAME FATHER S HOME ADDRESS FATHER S PHONE # / / month/day/year HIS DATE OF BIRTH / / month/day/year FATHER S OCCUPATION BUSINESS PHONE # MOTHER S NAME HER DATE OF BIRTH / / month/day/year MOTHER S HOME ADDRESS MOTHER S PHONE # MOTHER S OCCUPATION BUSINESS PHONE # LANGUAGE PROFICIENCY Besides English and French, do you speak any other languages? If so, which ones and how fluently? Are you currently enrolled in FR126? YES NO Please list the French courses you have taken at Colby and the grades received. If you haven t taken any Colby French courses, indicate why you are eligible to take this course: ACADEMIC PROFICIENCY Briefly describe the academic goals you would like to accomplish during the Paris Jan Plan. 1

2 FR127 is an intensive course; we cover a semester s worth of grammar in one month. What kind of strategies do you plan to use to keep up with this fast pace? Specifically, please explain how you will adjust to studying much more grammar than you have in your previous, non-intensive language classes. ACADEMIC ADVISOR S APPROVAL To be signed by student s academic advisor The above-named student has spoken to me about the FR127 Jan Plan in Paris, France. I am satisfied that this is the appropriate course for this student in January NAME (please print) SIGNATURE DATE / / month day year PARENT OR GUARDIAN'S STATEMENT I have reviewed the program information available and hereby give (student s name) my permission to participate in Colby s FR127 program in Paris, France in January I agree to meet the above-mentioned student s expenses, including all costs and fees, for the duration of the program. NAME (please print) SIGNATURE DATE / / month day year STUDENT S STATEMENT I acknowledge that there are risks inherent in connection with the transportation, housing, and activities of any off-campus program and that there are additional risks inherent in off-campus programs in foreign countries due to different standards of police protection, political stability, different rules of law, and cultural differences. As between Colby College (and its employees) and me, I accept and assume such risks and additional risks, including the risk of bodily injury, death or property damage in connection with my participation in this off-campus program. SIGNATURE DATE / / month day year 2

3 GENERAL INFORMATION ABOUT THE FR127 PARIS JAN PLAN Director: Marina Davies Telephone: (six hours ahead of EST) On-Campus Representative: Adrianna Paliyenko After the information session, if you have any questions about the Jan Plan, please contact Professor Davies first. FEE Cost of Jan Plan (including round-trip flight from Boston to Paris, based on enrollment of 12 students and subject to change): $3300 This is a zero sum budget. Should there be substantial money left in the account after the Jan Plan is over, this money will be refunded in equal parts to participating students. This fee covers transportation to and from the Paris airport, a monthly transportation pass for the bus, subway, & tramway, room & board in a foyer, including breakfast & your choice of lunch or dinner, and required class outings. The fee specifically does not cover: course books (which will be available for purchase at the Colby bookstore in December), supplies, any personal travel, and one meal a day. The amount you spend in addition to the Jan Plan fee will vary, depending on where you eat lunch, how much traveling you do on the weekends, etc. All students are expected to take the group flight on Sunday, January 1, unless they ask in writing to be exempt, explain why they consider this exemption necessary, and let Professor Davies know of their alternate travel plans before the Jan Plan deposit is due. ELIGIBILITY Students who have successfully completed FR126 are eligible to take this course, as are students whose placement test scores assigned them to FR127. If you have already taken FR127 or placed out of it, you are not eligible for this course but you are encouraged to apply to 200-level French Jan Plans in the future. Priority for this Jan Plan will be given to students who have already demonstrated an interest in French studies or departmental activities, and students who have not yet studied abroad. JAN PLAN SCHEDULE Sunday, January 1, 2017: Departure from Boston January 2: Arrival in Paris January 3: Class begins January 26: Final exam January 26: Class dinner Friday, January 27: Return to Boston Classes will be held Monday-Friday mornings in one of the foyer classrooms. Individual students may have appointments with Professor Davies in the early afternoon. Students will be evaluated every day through written quizzes, dictations, and/or oral exercises such as dialogues. Therefore, students should expect to devote a good chunk of their free time each day to preparing for the next day s sessions. REQUIRED WORK Daily participation daily quizzes weekly tests short essays final exam 3

4 ATTENDANCE POLICY Given the intensive nature of this course and the short length of the January term, there will be no absences allowed, except for serious illness. To be eligible to apply to this Jan Plan, you must be able to arrive in Paris in time for the first class and only leave Paris after the final exam; there are no exceptions. FOYER, MEALS, AND ACTIVITIES The recently remodeled FIAP foyer has double rooms, each with two desks, two closets, and a private bathroom. It is staffed 24 hours a day. The foyer has wireless Internet access. Students receive fresh towel and linen service and can use an on-site laundry room, for which tokens can be purchased in the lobby; therefore, there is no need to pack a month s worth of clothes. Students receive a buffet-style Continental breakfast in the dining room reserved for long-stay residents. Board includes either lunch or dinner at the foyer, which can accommodate certain dietary restrictions, including vegetarianism. The foyer will give us a welcome reception/soirée after our arrival. They also have an activities director who is available if the students wish to organize dances, plays, or other entertainment and cultural activities. Creative and artistic students are encouraged to take advantage of this free resource! EXPLORING PARIS All students will receive an unlimited public transportation pass for the month of January. If you organize your study time wisely, you should be able to explore Paris on a daily basis. We will go on several group outings and Professor Davies will suggest some sights upon your arrival. You are also encouraged to ask her for recommendations that are in line with your particular intellectual, cultural, musical, artistic, or personal interests. Although Paris is much safer than a comparable U.S. city, it is still a good idea to do your exploring with another student, particularly in the evening. PERSONAL TRAVEL During the weekends, students have the choice of staying in Paris or traveling in France or to nearby European countries. You must however attend all Friday and Monday classes. Bargain seekers should consider choosing a destination at the last minute; for example, there are good last-minute deals on weekend getaways at (click on Bons plans, Dernière Minute ). ENROLLMENT To enroll in this Jan Plan you should: 1) Be eligible for FR127 2) Submit the 2-page application form to Ms. Wood by Monday, September 26, You will receive an message on the status of your candidacy by Friday September 30. Once accepted, you are required to submit a deposit of $500 to Student Financial Services by Friday, October 14. You will not be enrolled in the course until this deposit is received. This deposit, applied to the enrollment fee, is not refundable if you decide at a later date to drop out of the Jan Plan. If you are not accepted to this Jan Plan, you will be able to enroll in another Jan Plan during the normal course selection time. If you are accepted to this Jan Plan, you must respect all the document deadlines (see the list below). All documents must be submitted in hard copy to Ms. Wood. If the Jan Plan is cancelled for any reason, full refund will be made of any deposits or fees paid. 4

5 Paris Jan Plan dates and deadlines September 26: The 2-page application form is due. This is the only form due on this date. To do immediately after being accepted into this course: 1) Apply for a passport and/or make sure that your current passport will be good through at least May You can apply at any US Post Office. Elm City Photo on 257 Main Street does passport photos. 2) Contact me and the Off-Campus Study office if you are not a US citizen and France requires citizens from your country to apply for a visa. October 14: $500 deposit due to SFS. See below for details. October 19: 1) Submit the risk form ( Agreement for Participation and Assumption of Risk ) 2) Send me an message with the following: the exact name as it appears on your passport, the passport number, its expiration date, the sex listed, your birth date, and your home phone number. If you do not have a passport yet, send me the name exactly as it will appear. October 31: 1) Submit the 3 health forms (medical release, health history, and mental health history). Go to the Health Center or your own doctor. Make an appointment early. The Health Center cannot accommodate everyone at the last minute. 2) Submit 3 good, clear copies of your passport. December 1: Pay balance at Student Financial Services. If you miss this deadline you forfeit your $500 deposit. There are no exceptions. Early December: 1) Purchase our course books in the Colby Bookstore and pick up a course packet from the French department. I will notify you when the books/packet are ready for you. 2) I ask that one student s me to volunteer to be the group representative during the flight. This person would be responsible for texting or ing me if the flight were delayed. January 1: Departure from Boston Logan airport. I will send you the flight details as soon as I have them. It is the responsibility of each student to arrive at the airport 3 hours before the flight departure. If you miss the flight, you will have to purchase another ticket to get to Paris. I will be waiting for you at the Paris airport (Roissy Charles de Gaulle)! 5

6 Jan Plan 2017 Trips Payment Information for Students 1. The $500 Deposit is due by Friday, October 14, The student account must be paid in full before a Jan Plan deposit will be considered as such. Students may view their "Student Account Statement' under the 'Finances' tab after logging into their mycolby Portal. 3. Credit, debit, or ColbyCard payments cannot be accepted for this purpose. This includes, but is not limited to, Visa and MasterCard. 4. An Electronic Payment (ACH) from a U.S. checking or savings account can be made by going to: This requires Colby ID, bank routing, and account numbers. Students should choose Student Account Tuition Bill under the Pay To section. In order to be added to the Jan Plan roster, the student must also send an to tuition@colby.edu to indicate for which Jan Plan the deposit is intended. 5. Payments by cash or check can be made in Student Financial Services, first floor of Garrison- Foster (Health Center) during normal business hours 8:30am to 4:30pm Monday through Friday. Students must indicate to which Jan Plan the payment applies in order to be added to the roster of interested participants. 6. The $500 deposit is non-refundable. If a student withdraws from the trip, they will be charged for the forfeited deposit as well as any other expenses which have been incurred. 7. Final payment is due before December 1, 2016, when trip leaders will be notified of any unpaid balances. 8. There is no Colby Grant available for Off Campus Jan Plans. We hope this information is helpful as you make plans for your Jan Plan Trip. The Student Financial Services Team sfs@colby.edu

7 Colby College Off-Campus Study AGREEMENT FOR PARTICIPATION AND ASSUMPTION OF RISK (For study on a COLBY JAN PLAN PROGRAM) COMPLETE, SIGN & RETURN TO MS. WOOD BY OCTOBER 19 STUDENT NAME: COLBY I.D.# JAN PLAN IN FRANCE: YEAR: By signing below I confirm that I have read, understood, and agree to observe Colby College s rules for participation in an offcampus study Jan Plan program and that I understand Colby s relationship to my Off-Campus Study Jan Plan ( Program ). I have shared this Off-Campus Study and Assumption of Risk Agreement with my parent(s) or guardian. Specifically, by signing below, I acknowledge and agree that: Academic, Financial and Conduct: I will forfeit the deposit if I decide not to attend the Program. I have freely chosen the Program, and thus my participation in this Program in one or more foreign countries or offcampus destinations is purely voluntary. I have read, or will read, and am responsible for knowing and understanding the contents of, any and all materials supplied by Colby to prepare me for this experience. I am fully and personally responsible for completing all Program requirements, including the timely submission of all forms and documents necessary prior to departure. Should I have or develop legal problems while on the Program, I will attend to the matter with my own personal funds. Colby is not responsible for providing any assistance under such circumstances. Colby reserves the right to make cancellations, changes or substitutions in the Program in the case of emergencies or changed conditions, including, without limitation, war, strike, weather, government restrictions or regulations, or acts of God, and refund will be made only of those funds not actually used or committed. As a Colby student studying off-campus, I will conduct myself in a manner compatible with local laws and regulations. As a Colby student studying off-campus, I am required to comply with the Colby College Code of Student Conduct. In the event that the Program leader, in his or her exclusive discretion, should determine that my conduct is detrimental to the Program or to other participants, the leader may terminate my participation in this Program. If my participation is terminated in this way, Colby may insist that I make any return travel arrangements myself, at my own expense. I will not illegally buy, sell, or use drugs at any time. I will participate in all classes and/or scheduled activities unless I am ill or prevented from attending for causes beyond my control. I grant Colby permission to reproduce in their campus yearbooks, catalogs or other advertising or promotional materials any photographs, movies, or sound recordings of me taken while I am participating in the Program, and also any written statements I may make concerning the Program. Travel & Transportation: Travel Risks include, but are not limited to, delays in transportation, changes in the means of transportation, weather, vehicle accidents, strikes, wars, natural disasters, pickpockets, official corruption, or other unforeseen causes or unfortunate outcomes involving travel. Travel Risks may be involved in going to, from and within foreign countries and off-campus destinations. Many of these risks are not present on the Colby campus. I have reviewed the safety information for France on the U.S. State Department Country Information page ( I am aware that new information may become available closer to departure time and I will be monitoring such information through the State Department website. I realize that there is no Colby College faculty member on site in France and that students are not accompanied on flights to and from France. I accept full responsibility for covering any loss or damage caused by a Travel Risk, whether through personal insurance, personal funds, or other personal sources. If I elect to travel in a vehicle I have hired or chartered, I understand that the qualifications of the driver and determination of the sufficiency of insurance coverage for the vehicle and driver are my responsibility. If I become detached from the Program group, fail to meet a scheduled departure, or become ill or injured, I will bear all responsibility and costs to seek out, contact, and reach the group at its next available destination. Health and Medical: Biomedical Hazards include, but are not limited to, infectious, tropical, parasitic and other diseases, viruses or bacteria; contaminated water or food; and insect, spider, snake, fish or animal bites. Please return to Ms. Wood by October 19. Page 1 of 2

8 Colby College Off-Campus Study AGREEMENT FOR PARTICIPATION AND ASSUMPTION OF RISK (For study on a COLBY JAN PLAN PROGRAM) I may visit areas where certain Biomedical Hazards are present that are not commonly encountered on the Colby campus; these may be definite and significant risks in certain countries and destinations. Colby cannot recommend precautions against Biomedical Hazards appropriate for each individual. Prior to participation in the Program, I will consult with a health care practitioner of my choice in order to become familiar with Biomedical Hazards that may be encountered in the Program destination(s), and to obtain the appropriate means of Medical Prevention or mitigation. I am aware of my personal medical needs. I further recognize that adjusting to life in a new culture, which often involves changes in diet and/or climate and being away from the support systems I currently have, can be a stressful and emotionally challenging experience and that underlying health-related concerns, including those which may be under control at home, may be exacerbated by these stresses. Having consulted with appropriate family members and/or care providers who are familiar with my health history, I assure Colby that I have fully considered my readiness to participate in the Program and that there are no health-related reasons, physical or psychological impairments that, in the exercise of reasonable care, would preclude or restrict my participation in the Program, or would put myself or other in danger by my participation. I have completed or will complete honestly, accurately and fully any required pre-departure health forms. Water and food sources in off-campus locations may be contaminated. Building, vehicle, and other safety standards at off-campus destinations may be less stringent than those at home. Providers of food, water, shelter and transportation are not agents of, nor represented by, Colby. I will exercise reasonable and/or recommended precautions with respect to food, drink, personal hygiene, personal conduct, and exposure to known disease risk factors (including sexual contact and behavior and alcohol use). I further agree to follow any health guidelines, which I receive before or while participating in the Program. I am aware of the coverages and limits of the Student Accident & Sickness Insurance Plan and/or my own health insurance that applies to me. I have arranged for whatever insurance I consider adequate to meet any and all needs for payment of medical care while off-campus. I grant Colby full authority to take whatever action it feels is warranted under the circumstances regarding my physical and mental health and safety, including placing me, at my own expense, in a hospital at any point for medical services and treatment, or if no hospital is available, to place me in the hands of a local health care provider for treatment. Colby is further authorized to return me to the United States or to another country for medical treatment if necessary. I assume all risk for the cost of my medical care, including transportation and hospitalization, while in, or in transit to or from, any off-campus destination. Assumption of Risk: I hereby specifically ASSUME THE RISK of all potential or actual perils, hazards, costs and damages attendant to my participation in the Program, including but not limited to, Biomedical Hazards, Travel Risks, bodily illness, personal injury, dismemberment or death, lawful or unlawful detention (i.e., jail or kidnapping), deprivation, disappearance, damage, destruction or theft or loss of personal property (including luggage and personal effects). Applicable Law, Entire Agreement: I agree that this COLBY COLLEGE OFF-CAMPUS STUDY AND ASSUMPTION OF RISK AGREEMENT FOR PARTICIPATION (COLBY JAN PLAN PROGRAM) is meant to be as broad and inclusive as permitted by, and will be construed under, Maine law, and that courts in Maine will serve as the venue for any legal proceedings incident to the Program. The terms of this agreement are severable, such that if a court of law holds any term to be illegal or unenforceable the validity of the remaining portions will not be affected. This agreement represents the entire agreement, and supersedes any prior representations, whether written or oral, made by Colby concerning the Program. CAUTION: READ BEFORE SIGNING Student Signature: Dated: If student is under 18, a Parent/Guardian must sign below: Parent or Guardian Name: Signature: Relationship: Date: Please return to Ms. Wood by October 19. Page 2 of 2

9 Off-Campus Study Emergency Medical Release and Consent to Treatment While studying on a Colby Jan Plan Off-Campus Program TO BE COMPLETED BY STUDENT: Please complete the following emergency information. This form, in conjunction with your Confidential Health History Form, will help to obtain appropriate attention in case of illness or emergency. Student Name: Colby Jan Plan Program: I agree to notify the Colby College Office of Off-Campus Study of any significant changes in my physical/mental health that occur after I submit this form. In the event of an emergency abroad, I authorize Colby College and its Jan Plan staff on-site abroad to: 1. Release my confidential health and mental health records to the Colby Jan Plan staff abroad and to health care providers abroad should the program deem such information to be essential to my wellbeing. 2. Hospitalize and/or secure proper treatment for me in case of medical emergency and in the event that: I am unable to communicate; The Colby Jan Plan staff is unable to communicate with my parent/guardian/emergency contact, and/or; According to the Colby Jan Plan staff s best judgment that further delay may jeopardize my physical well-being or life. 3. Notify my emergency contacts listed below Student Emergency Contact #1 Student Emergency Contact #2 Name: Name: Relationship: Relationship: Cell phone: Cell phone: Alternate phone: Alternate phone: Student Signature: Date: If Student is Under TO BE COMPLETED BY PARENT OR GUARDIAN: On rare occasions, a medical emergency arises and we are unable to contact a parent/guardian. In order to avoid delays, we request that the following permission be signed by the parent/guardian of the student. I hereby grant permission to the Colby College and its Jan Plan program staff on-site abroad to hospitalize and/or secure proper treatment for my son/daughter/ward (insert student s full name):, in case of medical emergency and in the event that: Neither my son/daughter/ward nor the Jan Plan Staff is able to communicate with me and/or; According to the Jan Plan Staff s best judgment that further delay may jeopardize the physical wellbeing or life of my son/daughter/ward. Parent or Guardian Name: Signature: Relationship: Date:

10 Off-Campus Study Confidential Health History To be completed by either your personal healthcare provider or Colby s Garrison-Foster Health Center Student Name: Jan Plan Destination: TO THE HEALTHCARE PROVIDER: Thank you for taking the time to meet with this student preparing to study abroad. Living and studying in an unfamiliar environment can be an enriching experience as well as a physically and mentally challenging one that has the potential to trigger and/or exacerbate emotional health concerns. It is important to be aware that some health support services abroad may be limited or not available in the same capacity as they are on Colby s campus or in the U.S. generally. For this reason, we encourage all students to share information about their health history so that we can prepare them properly for their experience and make arrangements for any special accommodations, if necessary. Please provide a careful and complete evaluation of this student s health and how it may be affected by the Jan Plan study abroad experience. In order to ensure the student s well being, we expect full disclosure of any health history that could be potentially problematic for a student overseas. Discuss possible accommodations the student should make or discuss with program staff. Please consider, in particular, the case of an unconscious student being treated in a hospital with this report constituting the sole medical history. Please give as much detail as possible in answering the following questions: Date of Examination Student s general state of health: Excellent Good Fair Poor Does the student have any dietary restrictions? Yes No Please specify: Does the student have any allergies to: Foods Yes No Specify: Environment Yes No Specify: Medication Yes No SPECIFY MEDICATION NAME, NOT BRAND NAME: Does the student have any history of physical disability, chronic illness or a mental health condition that might require attention during a Jan Plan abroad? Yes No Please specify or attach additional information: Does the student use any regular medication prescription or otherwise? Yes No Please specify medication name not brand name - and dosage:

11 Is the student presently receiving treatment for a physical or mental health condition? Yes No Please specify: Note: Student will fill out a Confidential Mental Health History form. This form will be sent directly to the student. Is there any serious impairment of: Eyesight Yes No Hearing Yes No Speech Yes No Date of last tetanus shot Please complete one of the following and attach any additional medical information. I have examined and believe him/her to be physically qualified to participate effectively in a Jan Plan program of study and travel abroad. or I have examined and s/he is under treatment for. S/he will require a letter from his/her treating practitioner before qualifying for Jan Plan study abroad. Date Name of Physician Address & Phone _ Physician s Signature Please return the completed & signed form to Ms. Wood by October 31. For students participating In a Colby Jan Plan program off-campus PAGE 2 OF 2

12 Off-Campus Study Confidential Mental Health History Living and studying in an unfamiliar environment can be an enriching experience as well as a physically and mentally challenging one that has the potential to trigger and/or exacerbate emotional health concerns. It is important to be aware that mental health support services abroad may be limited and not available in the same capacity as they are on Colby s campus or in the U.S. generally. For this reason, we encourage all students to share information about their mental health history so that we can prepare them properly for their experience and make arrangements for any special accommodations, if necessary. TO BE COMPLETED & SIGNED BY STUDENT: Student Name: Colby Jan Plan Program Destination: Have you ever suffered from or been treated for (including the use of psychiatric medication): Mental Health Condition (e.g. depression, anxiety, eating disorder, adjustment issues)? Y N Substance Abuse (alcohol or other drugs)? Y N Indicate any services or accommodations you believe you will need to facilitate participation in the Colby Jan Plan program abroad. Note that Colby cannot guarantee that services or accommodations will be available in the region(s) where you will be studying. Are you currently in mental health treatment (including use of medications), or planning to seek treatment in the near future)? Y N If yes, please fill in and sign below and have your provider complete the Treatment Provider section below. By giving your treatment provider permission to communicate with the Office of Off-Campus Study (OCS), this will help OCS and your Jan Plan Leader on location provide a greater level of support. If no, please sign and date below. I, (student), give permission to (treatment provider) to confirm to Colby College s Off-Campus Study office that I have sought mental health treatment and to provide any additional information about me that would allow the Jan Plan staff on location to better understand and work to accommodate my needs. Student signature: Date: *TO BE COMPLETED AND SIGNED BY TREATMENT PROVIDER (If Applicable): (student s name) sought mental health treatment from me on the dates listed below. I believe the concerns addressed in treatment can be effectively managed by the above named student while she/he is studying for a Jan Plan abroad. Additionally, I recognize that mental health support services may be very limited while she/he is abroad. Dates of Service: If there is additional information you believe Colby s OCS office should have regarding the student to help ensure a successful Jan Plan study abroad experience, please submit that information as an attachment to this form. Provider s signature: Date: Provider s printed name: Phone number: Address: Please return the completed & signed form to Ms. Wood by October 31.