CUNY-Paris Exchange Program Application

PLEASE PRINT CLEARLY CUNY-Paris Exchange Program Application Name (as it appears on passport) First Middle Last Semester(s) Abroad Fall Spring Academic Year CUNY Home College CUNYFirst ID Cell/Telephone Gender Date of Birth Email Are you a Macaulay Honors College student? Yes No Are you enrolled in a Special Program (CUNY Baccalaureate, SEEK, etc.)? Yes No If yes, specify FOR OFFICE USE ONLY CHECKLIST (Missing pages of application) Emergency Contact Form Educational Background & Housing Preference Recommendation Form & Letter Placement Acceptance Form Pledge of Acceptance Physician s Statement Waiver and Release Agreement (Must be notarized) New York State Health Care Proxy Form Health Information Questionnaire Consent and Release Form Passport Color Copy Official/Unofficial CUNY Transcript Deposit Check (Does student s name and program appear on check?) Check # Bank Amount Date application received 1

Queens College Education Abroad CUNY-Paris Exchange Emergency Contact Form Please print neatly Part A: Participant Information First name Last name Home College Semester(s) Abroad GPA (Required minimum 2.65) City and Country of Birth Language Skills (other than English) Passport Information: * Passport cannot expire in or before: I have a passport that will still be valid six months after the end of the program* My passport is expired or will expire before six months after the end of the Program and I WILL RENEW IT IMMEDIATELY. Fall students: July after your semester ; Spring Students: December of the same year you are abroad Passport Number Home address City, state, zip code Emergency Contact (1) Part B: Emergency Contact Information Emergency contact person Relationship Address City, state, zip code Emergency phone Cell phone E-mail Emergency Contact (2) Emergency contact person Relationship Address City-state-zip Emergency phone Cell phone E-mail 2

Queens College Education Abroad CUNY-Paris Exchange Educational Background & Housing Preference EDUCATIONAL BACKGROUND Name of Home College Major(s) Minor(s) Career Goals FRENCH LANGUAGE COURSE HISTORY Number of semesters you have studied French Please list the college-level courses in French that you have already taken: Which types of courses would you ideally like to take in Paris? Which subjects? PLEASE NOTE: All of your classes will be in French. Therefore, you CANNOT take courses such as Science, Mathematics, Computer Science, etc. (see CUNY-Paris website for more info.) Apartment Dorm (limited and not guaranteed) HOUSING PREFERENCE Au Pair (limited and not guaranteed) If you are interested in becoming an au pair, do you have any particular skills or experience that you think would be usedful in finding a French family for you to stay with? Home-Stay (not free) 3

CUNY-Paris Exchange Program Recommendation Form To the Applicant: Please complete the top part of the form below: Applicant s Name I waive my rights to have access to this recommendation form. I do not waive my rights to have access to this recommendation form *NOTE: Recommendation Letter MUST be from a French Professor. -------------------------------------------------------------------------------------------------------------------- To the Recommender: Thank you for taking the time to recommend the applicant for the CUNY-Paris Exchange Program! Your recommendation will have two parts: (1) A letter on official letterhead indicating: a. How long, and under what circumstances, you have been familiar with the candidate and his/her academic work, and b. Your evaluation of why you would recommend this student for this experience. (2) Your evaluation using the form on the following page. There are two options for handing in your recommendation letter and form: (1) Please attach this form and the form on the following page to your letter of recommendation and place them in a sealed envelope with your signature across the seal. a. This envelope can be given to the candidate who is responsible for submitting the recommendation with their application packet, which are due on: October 15 (Spring Semester Abroad) April 1 (Fall Semester/Academic Year Abroad) (2) You may also email your recommendation letter and forms to the following email by the dates above: Mohamed.Tabrani@qc.cuny.edu Thank you for your time and consideration! Recommender s Name Recommender s Title Department College Telephone Number Email Recommender s Signature Date 4

CUNY-Paris Exchange Program Recommendation Form Please evaluate the applicant s suitability for participation in an exchange program: Level of maturity Excellent Good Fair Poor No opportunity to observe Level of responsibility Ability to adapt to new or unstructured circumstances Ability to relate well to others Open-mindedness 5

Placement Acceptance Form Conditions of Placement for Queens College Study Abroad Programs Timely Completion of Forms: I understand that my participation in a Queens College Study Abroad Program (hereinafter sometimes referred to as program ) is contingent upon returning all forms (application, registration, housing, etc.) and other materials, which may be requested by stated deadlines. Eligibility: I understand that my acceptance to participate in a Queens College Study Abroad Program is contingent upon my maintaining all eligibility requirements (academic, financial, and social/behavioral) as defined by Queens College and my home campus. My participation may be terminated by Queens College, my home or my host campus if I fail to remain enrolled at my host campus or fail to maintain other eligibility standards. I further understand that failure to remain enrolled as a student may affect my financial aid and/or program eligibility at Queens College, my home and/ or my host campus. Tuition/Fees Room/Meal, and other Fees: I agree to pay tuition/fees in a timely manner. I also agree to pay program fees in a timely manner. I understand that failure to make full payment of all required fees or to resolve other debts may result in the cancellation of any course registration and/or disenrollment. I understand that all financial obligations must be fulfilled prior to receiving transcripts or a diploma from Queens College. Deposits are not refundable after the original application deadline. Transcripts: I assume responsibility to request that an official transcript of the work attempted while on the program be sent back to my home campus if Queens College is not my home campus. Health Insurance: I understand that Queens College requires that I have adequate health insurance for the time period of the program, and that it is my responsibility to ensure that I am adequately covered for the period and place of my program. I further understand that my home and/or host campus (if other than Queens College) may require me to submit proof of coverage. Medical Matters: I will comply with any requirements for medical information relating to my participation in the program, including obtaining or documenting immunizations required by my home and/or host campuses. Personal Health and Safety: I understand that Queens College and/or my home and host campuses cannot guarantee my health and safety while on the program. I am responsible for acting prudently and exercising caution and common sense at all times. I also understand that I may be using different forms of transportation to participate in this program. I agree that Queens College as well as my home and host campuses are not responsible for personal injury, death, and/or loss or damage of property suffered by me during periods of travel with, and independent of, the program. Rules and Regulations: I agree to abide by all rules, regulations, and policies of Queens College and/or my home and host campuses governing my academic, financial, and social/behavioral status while on exchange. I understand that failure to conform to these rules and regulations may result in the termination of my exchange participation and that further disciplinary action may be taken by Queens College, my host and/or my home campuses. Release of information: By signing this Placement Acceptance Form, I hereby give permission to Queens College coordinators and/or my home and host campuses to collect and release information appropriate to my application for, and my participation in the program, including: letters of recommendation, transcripts, financial status with the campuses, report of conduct, and medical/counseling records. That information may be released between and among the campus coordinators and other appropriate officials of both the home and host campuses and Queens College. I further agree that my home and host campuses may disclose to one another, to Queens College, and to my parent, legal guardian, or spouse, any information which may impact my mental health or physical wellbeing while I m in the program. The permission granted hereunder shall survive the termination of my participation in the program. Hold-Harmless: I understand that my participation in Queens College Study Abroad Programs is voluntary. I understand that Queens College does not make any warranties of any kind, expressed or implied, regarding Queens College Study Abroad Program participation, including perceived quality of experience or services rendered. I further understand that Queens College and/or host college does not assume responsibility and disclaims any liability for any injury, loss, damage, or expense (personal, academic, financial, or other) suffered by me by reason of my participation in this program. Signature Date Print name Name of program 6

CUNY-Paris Exchange Pledge of Acceptance Name Program Participants are expected to observe local laws and customs, and exhibit good behavior. The college reserves the right to require any student to leave the program for reasons of personal behavior or academic standing. Participants in Queens College Programs Abroad are subject to the Rules and Regulations for the Maintenance of Public Order Pursuant to Article 129-A of the Education Law (the Rules and Regulations ). Five Inviolable Laws: 1. Students must maintain an adequate academic standard. 2. Violent, disorderly, or indecent behavior of any kind is prohibited and may result in suspension, expulsion, ejection, and/or arrest by the civil authorities in accordance with the Rules and Regulations. 3. Illegal drugs in any form are not tolerated and any student dependent upon their use should not participate in the program. Laws in most countries state that possession of any illegal drug is punishable by fine, imprisonment, and/or deportation. Students found to be using illegal drugs in any form may be subject to suspension, expulsion, ejection, and/or arrest by the civil authorities in accordance with the Rules and Regulations. 4. Attendance in all classes and class-related trips is mandatory. 5. Travel during the class periods is not allowed; students who break this rule risk being dismissed from the program with no tuition refund. I have read these rules and I agree to obey them during the time of my participation in the Education/Travel Abroad Program. I understand that violation of these rules may lead to probation or suspension. I understand that if for any reason I leave the program, I am responsible for all financial arrangements for my care and for transportation home. Signed Date 7

Physician s Statement TO THE APPLICANT: Please authorize by your signature below the release of any medical information that may be relevant in the opinion of your physician to your participation in the study abroad program. Your name Program name and location Application for: Spring 20 Fall 20 Summer 20 Winter 20 Academic Year 20 20 Length of term away Signature Date TO THE PHYSICIAN: Please indicate if the student named above has a history of chronic or disabling physical conditions; any allergies which may require either continuing or emergency treatment; any special dietary problems; or any other physical or emotional condition which might affect his/her wellbeing or that of fellow students while living or traveling outside the United States for an extended time. Please list the generic names for any prescription medicine the student requires which may not be readily obtainable abroad. Physician s name Address Signature Date A doctor s stamp is required. Queens College Education Abroad Office Fax: 718-997-5055 (This form must be returned to the Study Abroad Office by your Program s Orientation Meeting or else your registration may be jeopardized.) Participation, Waiver and Release Agreement 8

This Is a Release. Please Read Before Signing! I, ( Applicant ), am a student at College (the College ) of the City University of New York (the University ) and have agreed to participate in the College s international studies program (the Program ) in from, 20 until, 20 Participation, Waiver and Release Information (To be completed and signed by the participating student and, if under 18, his/her parent or legal guardian.) I wish to participate in the Activity, and in consideration for being permitted to participate in the Activity, I hereby represent and agree as follows: 1. I understand that participation in the Activity involves risks and hazards not found in study at the College, including risks involved in traveling, and I have sought and obtained information and advice that I feel are necessary and appropriate. I am fully aware of and voluntarily assume the risks and hazards connected with participating, and I hereby voluntarily elect to participate in the Activity. I acknowledge, accept, and assume all such risks, whether or not foreseeable and whether or not caused by the negligent or intentional acts or omissions of others. 2. I understand that, although the University has made every reasonable effort to assure my safety while participating in the Activity, there are unavoidable risks, and I hereby release and promise not to sue the City of New York, the State of New York, the College, the University, and the officers, employees, agents, or representatives of any and all of them ( Released Parties ) for any damages or injury (including death) caused by, deriving from, or associated with my participation in the Activity, except for such claims, damages or losses may be caused by the gross negligence or willful misconduct of the Released Parties. It is my express intent that this Release binds my heirs, assigns, and personal representatives. 3. I represent that my statements herein are accurate and complete and that my agreement to the provisions herein is wholly voluntary, and further understand that, prior to signing this Release, I have the right to consult with the adviser, counselor, or attorney of my choice. 4. I will become informed of, and will abide by, all such laws and standards surrounding the Activity and assume responsibility for my actions, understanding that the circumstances of an Activity may require a standard of behavior that may differ from that applicable on campus. I will comply with the University s rules, standards, and instructions, for student behavior generally and for the Activity, including the College s Code of Student Conduct and the Henderson Rules of Public Order (collectively, standards ). I acknowledge and understand that my compliance is important to the success of the Activity and to the University s/college s willingness to permit future similar activities. I waive and release all claims against the University that arise at a time when I am not under the direct supervision of the University or that are caused by my failure to remain under such supervision or to comply with such rules, standards and instructions. 5. I agree that the University has the right to enforce the standards and conduct described herein, in its sole judgment, and that it may impose restrictions, up to and including removal and termination from the Activity, for violating these standards or for any behavior detrimental to or incompatible with the interest, harmony and welfare of the College, the University, the Activity or other participants. If I am terminated from the Activity, I consent to going home at my own expense with no refund of fees. 6. I have or will obtain and maintain health, accident, disability, hospitalization, and travel insurance as I deem necessary to participate in the Activity, and I will be responsible for the costs of such insurance and for any expenses not covered by insurance. 7. I have no known physical or health-related reasons or problems that preclude or restrict my participation in the Activity or I have disclosed to the College any physical, mental, and emotional conditions or problems, permanent or temporary, including special dietary and medication needs, or the need for visual or auditory aids that might impair my ability to participate in the Activity, and I hereby release each of the Released Parties from any and all claims, injuries (including death), damages, or loss 9

arising out of my failure to disclose such conditions or problems. 8. The University may, but is not obligated to, make any decisions and take any actions regarding my health and safety that it considers to be warranted under the circumstances. I hereby authorize the University to make such decisions and take such actions. I agree to pay all expenses relating thereto and release the University from any liability for any such actions. 9. I am assuming full financial responsibility for all costs and expenses incurred by me in connection with the Activity, including, without limitation, financial responsibility for damage or destruction to property of third parties. 10. I will not hold myself out as having the power or authority to bind or create liability for the College or the University. 11. I agree that should any provision or aspect of this Off-Campus Activity Participation, Waiver, and Emergency Contact Form be found to be unenforceable, that all remaining provisions will remain in full force and effect. 12. This waiver and release represents my complete understanding with the College and the University concerning their responsibility and liability for my participation in the Activity. It supersedes any previous or contemporaneous understandings I may have had with the College or the University on this subject, whether written or oral, and cannot be changed or amended in any way without my written concurrence. I have read this release form carefully before signing it. Signature State Of CUNY ID# County Of On this day of, 20, personally appeared before me and known to me to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same. Notary Stamp Notary Public Note: If Applicant is under the age of 18, then this page must be completed, signed, and notarized. *** 10

IF APPLICANT IS UNDER THE AGE OF 18: I, Print full name (a) am the parent or legal guardian of the Applicant; (b) have read the foregoing Waiver and Release Agreement (including such parts as may subject me to personal financial responsibility); (c) am and will be legally responsible for the obligations and acts of the Applicant as described in this Release; and (d) agree, for myself and for the Applicant, to be bound by its terms. Signature of Parent or Guardian STATE OF Social Security # COUNTY OF On this day of, 20, personally appeared before me and known to me to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same. Notary Stamp Notary Public 11

Health Care Proxy Form Instructions Office of New York State Attorney General This is an important legal form. Before signing this form, you should understand the following facts: 1. This form gives the person you choose as your agent the authority to make all health care decisions for you, except to the extent you say otherwise in this form. Health care means any treatment, service, or procedure to diagnose or treat your physical or mental condition. 2. Unless you say otherwise, your agent will be allowed to make all health care decisions for you, including decisions to remove or provide life-sustaining treatment. 3. Unless your agent knows your wishes about artificial nutrition and hydration (nourishment and water provided by a feeding tube), he or she will not be allowed to refuse or consent to those measures for you. 4. Your agent will start making decisions for you when doctors decide that you are not able to make health care decisions for yourself. You may write on this form any information about treatment that you do not desire and/or those treatments that you want to make sure you receive. Your agent must follow your instructions (oral and written) when making decisions for you. If you want to give your agent written instructions, do so right on the form. For example, you could say: If I become terminally ill, I do/don t want to receive the following treatments... If I am in a coma or unconscious, with no hope of recovery, then I do/don t want... If I have brain damage or a brain disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, I do/don t want... I have discussed with my agent my wishes about and I want my agent to make all decisions about these measures. Examples of medical treatments about which you may wish to give your agent special instructions are listed below. This is not a complete list of the treatments about which you may leave instructions. *artificial respiration *cardiopulmonary resuscitation (CPR) *antibiotics *blood transfusions *dialysis *transplantation *electric shock therapy *psychosurgery *abortion *sterilization *artificial nutrition/hydration (nourishment/water provided by feeding tube) Talk about choosing an agent with your family and/or close friends. You should discuss this form with a doctor or another health care professional, such as a nurse or social worker, before you sign it to make sure that you understand the types of decisions that may be made for you. You may also wish to give your doctor a signed copy. You do not need a lawyer to fill out this form. You can choose any adult (over 18), including a family member or close friend, to be your agent. If you select a doctor as your agent, he/she may have to choose between acting as your agent or as your attending doctor; a physician cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home, or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. You should ask staff at the facility to explain those restrictions. You should tell the person you choose that he/she will be your health care agent. You should discuss your health care wishes and this form with your agent. Be sure to give him/her a signed copy. Your agent cannot be sued for health care decisions made in good faith. Even after you have signed this form, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped if you object. You can cancel the control given to your agent by telling him/her or your health care provider orally or in writing. 12

Filling Out the Proxy Form Items 1 5 below are helpful instructions for filling out the Health Proxy Form on the following page. These instructions correspond to the numbered areas on the Health Proxy Form. Item 1: Write your name and the name, home address, and telephone number of the person you are selecting as your agent. Item 2: If you have special instructions for your agent, you should write them here. Also, if you wish to limit your agent s authority in any way, you should say so here. If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decision to consent to or refuse life-sustaining treatment. Item 3: You may write the name, home address, and telephone number of an alternate agent. Item 4: This form will remain valid indefinitely unless you set an expiration date or condition for its expiration. This selection is optional and should be filled in only if you want the health care proxy to expire. Item 5: You must date and sign the proxy. If you are unable to sign yourself, you may direct someone else to sign in your presence. Be sure to include your address. NOTE: Two witnesses at least 18 years of age must sign your proxy. The person who is appointed agent or alternate agent CANNOT sign as a witness. 13

New York State Health Care Proxy Form 1. I, hereby appoint (name) as my health care (name, home address, and telephone number) agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect when and if I become unable to make my own health care decisions. 2. Optional instructions: I direct my agent to make health care decisions with my wishes and limitations as stated below, or as he or she otherwise knows. (Attach additional pages if necessary.) (Unless your agent knows your wishes about artificial nutrition and hydration (feeding tubes), your agent will not be allowed to make decisions about artificial nutrition and hydration.) 3. Names of substitute or fill-in agent if the person I appoint is unable, unwilling, or unavailable to act as my health care agent. (name, home address, and telephone number) 4. Unless I revoke it, this proxy shall remain in effect indefinitely, or until the date or conditions stated below. This proxy shall expire (specific date or conditions, if desired): Signature Address Date Statement by Witness (must be 18 or older) I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence. Witness 1 Signature Print Name Address Witness 2 Signature Print Name Address NOTE: Neither witness should be the SAME person named as proxy (health care agent). 14

Queens College, Study Abroad Office Health Information Questionnaire Name Birth date Male Female Program The purpose of this form is to help Queens College be of maximum assistance to you should the need arise during your study abroad experience. Mild physical or psychological disorders can become serious under the stresses of life overseas. The program needs to be notified of any medical or emotional problems, past or current, which might affect you in a foreign study context. The information you provide will remain confidential, and will be shared with program staff, faculty, or appropriate professionals only if pertinent to your own well-being. Queens College may not be able to accommodate all individual needs or circumstances. This information does not affect your admission to the program. Please note: Nondisclosure of a physical or medical condition may affect our ability to provide information relevant to your specific needs abroad. MEDICAL HISTORY Yes No 1. Are you generally in good physical condition? (If no, please explain.) Yes No 2. Have you ever been treated or are you currently being treated for any psychological or emotional problems? (If yes, explain.) Yes No 3. Do you have any allergies to drugs or foods? (If yes, explain.) Yes No 4. Are you taking any medications? (If yes, explain.) Yes No 5. Have you had any major injuries, diseases, or ailments in the past five years? (If yes, explain.) Yes No 6. Are you a vegetarian or are you on a restricted diet? (If yes, explain.) Yes No 7. Do you have other medical/mental conditions, or learning or physical disabilities, that would require accommodation? Is there any additional information that would be helpful for the program to be aware of during your study abroad experience? (If yes, explain.) Please use this space to explain answers to the above questions. You may write on the back of this form, if necessary. I certify that all responses made on this Health Information Questionnaire are true and accurate, and that I will notify Queens College hereafter of any relevant changes in my health that may occur prior to the start of the program. I further understand that, in the event of an emergency abroad, Queens College reserves the right to notify my parent(s) or guardian. Signature of Participant Date 15

Event: Date: Place: Creative Services CONSENT AND RELEASE FORM I am a participant in the above Event. I understand that the Event will be recorded. I hereby authorize The City University of New York and those acting pursuant to its authority (collectively, CUNY ) to: (1) Photograph, videotape, audiotape, transcribe or otherwise record, in any medium, my participation in the Event; (2) Use, modify, reproduce, publish, exhibit and/or distribute any and all such recordings, in whole or in part, in any manner or medium now known or hereafter developed (including without limitation, the classroom, print publications, webcasts, podcasts, television, and websites), an unlimited number of times in perpetuity throughout the world, for any purpose that CUNY may deem appropriate, including without limitation educational and promotional uses; and (3) Use or license others to use my name, image and biographical material in connection with any such recordings or uses, but not as an endorsement of any product or service. I hereby waive the right to inspect or approve any such recordings and uses. I understand that CUNY will be the owner of all rights in and to such recordings and uses, subject to the restrictions described in this consent and release, and retains the right not to use the recordings for other than archival purposes. I hereby release and hold harmless CUNY from liability for any and all claims by me in connection with CUNY s activities as authorized by this consent and release. I am age 18 or older, or if I am under the age of 18, my parent or legal guardian will review this form and act on my behalf. I have read and fully understand the terms of this consent and release. Date Printed Name Email Cell Phone CUNYfirst ID Signature 16

Passport & Transcript Form (1) Please attach a color-copy of your passport page that includes for Passport Number, Name, Nationality, Date of Birth, Place of Birth, Issue Date and Date of Expiration. (2) Please attach an Official or Unofficial CUNY Transcript. (This form, if not included with your application, must be return to the Study Abroad Office at least 45 days before the start of your program or else your registration may be jeopardized.) 17