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GEP Application Form

University of Illinois at Springfield
Study Away Programs
Application Form

required

1. Please check the appropriate box:

UIS student applying for a UIS program

UIS student applying for a non-UIS program

Non-UIS student applying for a UIS program

2. First Name:

3. Last Name:

required

4. Are you a UIS student

Yes

No

Other, please specify:

Enter text

5. If you checked no and you are a student, please indicate which college/university you are attending at present

6. If you are not a student, please indicate your current profession

If you are a student, complete questions 7 - 10 (skip if not a student)

7. UIN #(for UIS students)

If you are a student, complete questions 7 - 10 (skip if not a student)

8. Major

9. Year in school and/or credit hours earned by application deadline:

10. Anticipated date of graduation:

Program to which you are applying:

required

11. Which program are you applying for?

A) UIS Short Program (complete questions 12 - 14)

B) UIS Exchange Programs ( complete questions 15 - 16)

C) Non-UIS Programs (complete questions 17 -19)

12. A) UIS Short Term Study Programs: Program name:

13. A) Program dates

14. A) If you are applying for a UIS short-term study program are you intending to enroll for credit?

Yes

No

15. B) UIS Exchange Programs: Program name:

16. B) Program dates:

17. C) Non-UIS Programs
Program Name/ Sponsoring Institution

18. C) Program Dates

19. C) Provide the following information IF YOU ARE APPLYING FOR A NON UIS program: - Contact Information (Name, Address, Phone, Email) - Cost of program (in USD) - Program Prerequisites

Contact Information

20. Current Address

21. City

22. State

23. Zip code

24. Telephone:

25. E-mail

26. Permanent home address (if different)

27. City

28. State

29. Zip code

Emergency Contact Person Information: Complete questions 30 - 36.

30. Full Name:

Emergency Contact Person Information: Complete questions 30 - 36.

31. Address

32. City

33. State

34. Zip code

35. Telephone

36. E-mail

Travel Related Information

37. Date of Birth

Travel Related Information

38. Place of Birth

39. Citizenship

40. If not a U.S. Citizen please enter your alien registration number or your visa type (F1, J1, etc.)

required

41. Do you have a valid passport?

Yes

No

42. Passport Number

43. Expiration Date

44. Health Information: Please list any disabilities (hearing, learning, orthopedic, psychological and chronic, etc.) you have. Please note that most UIS seminars require moderate walking and that some of the sites that will be visited on UIS seminars might not be completely ADA accessible.

45. List any medical conditions (allergies, etc.) you have

46. List any dietary restrictions you may have

47. List all prescription medicines you are taking

48. Health Insurance: The University of Illinois system maintains a group policy for international heath insurance coverage for all participants in a UIS program of study outside of the USA, including conducting research, fieldwork and internships.
For individuals who are approved to participate in a study abroad program through UIS enrollment in Gallagher Student Health and Special Risk Insurance is required and enrollment is automatic upon approval. Individuals who have insurance plans which meet or exceed the benefits offered by Gallagher may petition for an exemption waiver.

Information on the Gallagher policy and the exemption waiver can be found on the Health and Safety web page on the Global Experience Program web site.

Qualifications:

49. List the courses that you have taken that are required or relevant to your proposed program of study.

Qualifications:

50. List any extra curricular activities, hobbies, awards, honors, and/or University recognition (we use this information for home stays for selected programs):

51. List recent work experience, internships or other relevant information (we use this information for home stays for selected programs):

52. In the box below prepare an essay detailing (or upload it in question 53):

your preparation for your study abroad experience;
the academic/internship program you intend to pursue while abroad;
and what your plans are for your final semesters at UIS as well as after you complete your studies.

Your essay should address why the study abroad experience is important to you and how it will contribute to your overall academic plans and/or life goals. You should explain why you have chosen this specific program and country. You should also indicate what experience you have had with adjusting/adapting to different living situations, academic environments and social customs.

53. Essay upload (maximum file size: 15MB)

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