Applyingfor:( Checkone) FALL 2012

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

E-mail:

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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PERSONALINFORMATIONSHEET

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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Applyingfor:(√checkone) FALL 2012

Name:

firstmiddlelastpreferred

StudentID#: Dateofbirth(mm/dd/yy): / / Sex: MF Major: YearinSchool:2ndSem.Soph Junior Senior Graduate

Concentration: GraduationDate(Month/Year):

School:______

AREYOUCURRENTLYSTUDYINGABROAD(asof______2012):YES NO

Currentmailingaddress:

City,State,ZIP:

Dateuntilwhichthisaddresscanbeused:

Currentphone(s)#,besttime:

Ithaca College E-mailaddress:

Permanentaddress:

City,State,ZIP:

Phone(s)#,besttime:

Pleaseindicatethenameandaddresstobeusedforbillingandothermailings:

Parentorguardianname(s):

Address:

City,State,ZIP:

Homephone() Work:() Requiredmedicalinsuranceprovidedby:IthacaCollege Other:

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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Fall 2012 Applicants Academic Information

Name: StudentID#:

Major: Conc: :

CumulativeGPA: /4.0

AcademicAdvisor: Advisor’sSignature:

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

E-mail:

Total number of completed credits:

Totalsemestercreditscurrentlyenrolled: +

Totalsemestercreditsearnedbyendofcurrentterm: =

Internshipscompletedorinprogress:

GraduationDate:

/

monthyear

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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DATESCREDITSORGANIZATION /LOCATION

1. to

2. to

APPLICANTS:

• You MUST obtain your advisor’s signature. Please be sure to confer with your advisor concerning your academic progress.
• When choosing your electives, please put them in rank order with #1 being the most preferred.

ELECTIVE: CREDITS:

#1______

#2______

#3______

#4______

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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Pleaseinitial eachitem:

CONSENTFORM

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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1. IunderstandthatallparticipantsintheCornell in WashingtonProgramwillberesponsible fortheirown travel arrangementstoandfrom Washington, D.C.,andalltransportationneedswhileinWashington,andforthe chargesinvolved.

2.Iunderstandthatparticipants areresponsibleforthecostof housing,meals,laundry, books,supplies,telephone,and incidentals.

3.IunderstandthattheCollegereserves therighttocanceloralteranyoralloftheaspectsofthisprogram and/oralteritsscheduleofchargesshouldunforeseencircumstanceswarrant suchaction.

4.Iunderstandthattherearecredithourenrollmentminimumsand maximums,describedintheInformation

Sheetforthesemesterforwhichtheparticipantisapplying.

5.Iunderstandthat,beforethisapplicationwillbeconsidered,allparticipantsmustbeingoodacademic, judicialandfinancialstandingattheCollegeand in their current schoolofenrollment.

6.Iagreetomeetthescheduleofpaymentsinconnectionwiththisprogramas providedbyIthaca CollegeStudentFinancial Services.IthacaCollege’snormalbillingprocedureswillbe followedandregulartuition andfeerateswillbecharged.

7.____I understand that if I am accepted for this program, I will be subject to Cornell University’s code of conduct, rules, and regulations.

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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Ihavereadallthematerialsprovidedaboutthe programaswellastheinformation above,andI agreetoparticipateintheprogramunderthese terms.

Ihavereadallthematerialsprovidedabouttheprogram aswellastheinformation above,andIgivemy son/daughter/ward permissiontoparticipate,andIagree totheseterms.

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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STUDENT'SSIGNATUREDATEPARENT/GUARDIAN'S SIGNATUREDATE

Student’snametypedorprintedParent/Guardian’s nametypedorprinted

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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STUDENTCONDUCTCERTIFICATION

APPLICANT:Pleasecompletetheinformation belowandgivethisformtotheIthaca College Judicial Office.

Applyingfor:(√checkone) SPRING 2012OR FALL 2013

I amapplyingforadmission totheIthaca CollegeCIWProgram.

(printyour name)

StudentID#:

IherebyauthorizetheappropriateofficialsatIthaca Collegetoreleaseinformation regardingmyconductas anundergraduateand sendittotheAssistant Provost for International Studies to be considered for the Cornell in Washington Program. IfurtheragreetoabidebytheCornell Conduct Code whileIamattendingtheCornell in WashingtonProgram.

Student'sSignatureDate

The Cornell in Washington Program

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ITHACA COLLEGEJUDICIAL OFFICER:

Pleasecompletethisformandfaxto(607)274-5125orsenditto:

Cornell in Washington Program

Assistant Provost for

International Studies

214-1 CHS

IthacaCollege

Isthestudentcurrentlyingoodjudicial standing?

YES NO

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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Hasthestudenteverbeencitedformisconduct?

Hasthestudenteverreceivedasanctionmoreseverethanawrittenwarning?

YES NO

YES NO

The Cornell in Washington Program

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Ifyes,whatwasthenatureoftheinfraction and sanctionimposed(ineach case;useadditional pagesasneeded):

Signature

Name/Title Officephone

The Cornell in Washington Program

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ACADEMICRECOMMENDATION

APPLICANT: Pleasecompletetheinformationbelowandgivethisformtoafaculty memberinyourmajorwhoknowsyouwellenoughtoprovideaninformedassessmentofyouracademicstrengthsandweaknesses.

Applyingfor:(√checkone) FALL 2012

I, amapplyingforadmissiontotheCornell in Washington

(printyourname)

Program. IncompliancewiththeFamilyEducationRightsandPrivacyActof1974,asamended:

(√checkone)

Thisevaluationwillremainconfidential;Iwaivemyright toviewit.

Thisevaluationwillnotremainconfidential;Idonotwaivemyright toviewit.

Signature Date

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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REFERENCE: Pleasecompletethisform andfaxto(607)274-5125orsenditto:

Cornell in Washington Program

Assistant Provost for

International Studies

214-1 CHS

IthacaCollege

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

E-mail:

1.Howlongandinwhatcapacityhaveyouknowntheapplicant?

2.Pleaseevaluatethecandidateinthefollowingareas:

3.Pleasecommentonthecandidate'sstrengthsandweaknessesrelevanttohis/herability toperformaninternshipinNew York City. Please provideresponsesonanattachedpage. PLEASE DONOTWRITEONTHEBACKOFTHISFORM.

Signature

Name/Title Officephone

The Cornell in Washington Program

Phone (607)-274-3063•Fax (607)-274-5125

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ALLAPPLICANTSREADANDSIGNBELOW:

I have met with my advisor and reviewed the Cornell University website. I understand that it is my responsibility to complete all paperwork to secure and receive proper credit for my experience. All decisions regarding my application to the Cornell in Washington Program, made by the Assistant Provost for International Studies and/or the Cornell in Washington Program Director, in conjunction with the CIW Program staff, are final.

Signature Date

EMERGENCY CONTACT INFORMATION

Student’s Name:______

Student’s ID Number:______

Student’s Telephone Number:______

Student’s IC Email Address:______

Parent/Guardian Information:

Name:______

Relationship:______

Telephone Number:______

Email Address:______

Name:______

Relationship:______

Telephone Number:______

Email Address:______