Dominican Republic Application

Spanish Language and Culture in Oaxaca 2017

Application Instructions

DEADLINE MARCH 17, 2017

***This program may be cancelled if minimum enrollment is not met***

You are eligible to apply if you have completed a minimum of 12 hours at UIC, you are in good academic standing, you have the prerequisites for the Oaxaca course you wish to take, and you are a heritage speaker of Spanish (that means you learned it through your family and placed into Spanish 113, 114, or 204 at UIC).

If accepted, you are eligible to participate if you have no holds on your UIC account, you have no outstanding discipline record, you have paid all fees, you have turned in all required forms (medical, housing, behavioral contract, etc.) and you have attended all required pre-departure sessions.

To apply, you will need to attach a current UIC academic history including Fall 2016 grades from UIC portal (my.uic) along with Pages2-7 of this application by March 17, 2017. Please note that the program has rolling admission; if you apply before the deadline you will receive notification within three (3) working days whether you have been accepted.

If you are applying for a Spanish Department scholarship, also turn in the second half of Page 7 of this application.

A non-refundable program fee deposit of $155 (money orders ONLY) payable to the University of Illinois at Chicago must be submitted no later than March 29 in 1727 UH after you are accepted into the program. This amountis deducted from the cost of the program. If the program is cancelled, this fee will be refunded.

All students will be required to submit a Medical Form byApril17, 2017.An appointment with your physician may be necessary.

TIMELINE

March 17Application + UIC academic history due to the Spanish Department, 1722 University Hall.

March29Commitment to participate $155 program fee deposit due (made payable to the University of

Illinois; money order only). UIC summer registration opens.

April 17Attend mandatory orientation. Proof of UIC summer course registration, medical form, housing form, behavioral contract, and itinerary due. This means that you must have your airline ticket purchased.

May 25Final program fee installment ($1,499) due to the University of Illinois.

June 16Pre-departure class session. Time tbd.

June 18Arrive in Oaxaca

GENERAL APPLICATION, OAXACA, SUMMER 2017

LastName:First Name:

UIN:Date ofBirth:

Gender:(circleone)MFOther UICEmail:

PhoneNumber:

Race/ Ethnicity: Choose the category you most identify with (this is optional)

Native AmericanorAlaskan HispanicAsian orPacific Islander

Black orAfricanAmerican  White Other ______

U.S. Emergency Contact:

College (circle): LAS BA CADA ENG AHS EDU JACSW NUR PHR UPPA SPH

Major1:Major2:

Minor1:Minor2:

Transfer Student:  Yes  No Honors College: Yes  No GPPA:  Yes  No

Total transcript hours: ______UIC transcript hours: _____GPA: ______

Are you attaching your current UIC academic history including Fall 2016 grades from UIC portal (my.uic)to this application? IT IS REQUIRED.  Yes

Do you have a passport of a country other thantheUS? Yes  No

IF YES, :Are you registered at UIC through the Office of International Services?  Yes  No

Do you also have a US passport?  Yes  No

Current/last Spanish course taken at UIC (choose ONE):

 113  114  202  204  206  Other: ______

Course I would take in Oaxaca (choose ONE):

 114  202  204  206  363  399

STUDY ABROAD RELEASE & WAIVER

Name:

University IdentificationNumber:

Study Abroadprogram:Oaxaca Summer 2017

ACKNOWLEDGEMENT OF RISKS AND RELEASE OF RESPONSIBILITY

Certain potential risks to personal health and safety are associated with international travel and residence in a foreign country. You should not participate in a study abroad program unless you are willing to accept associated risks.

Neither the University of Illinois at Chicago nor its employees can guarantee the health and safety of participants in a study abroad program or eliminate all risks from study abroad environments.

All students must read and initial each statement in the section below. Sign the end of the document, and return this as part of your application packet. Students who fail to return this form will not be allowed to participate.

Initials

I understand and accept that there are certain risks associated with international travel and residenceina foreign country and that UIC/its faculty members cannot control theserisks.

I understand and accept that these risks may include exposure to potentially serious healthandsafety hazards such as: transportation accidents, storms, floods, earthquakes, and other natural disasters; infectious diseases, inadequate medical care, remote access to medical treatment; armed insurrections; and terroristactivities.

I understand and accept that the University of Illinois at Chicago is not in a position toguaranteemy personal health or safety during my participation in a study abroad program nor is the University responsible in any way for my personal decisions regarding my health andsafety.

I read, understood and agree to be bound by the “Conditions of Participation” and “StudentRightsand Responsibilities” that are part of this application.

In consideration of being allowed to enroll and participate in thisprogram,the undersigned hereby releases the University of Illinois at Chicago, its Board of Trustees, officers, agents and employees from any and all claims arising out of or in any way connected with this program and the undersigned’s participation in the program, including, but not limited to the risks as outlinedabove.

I understand that UIC reserves the right not to forward my applicationtoa program provider based on information collected during the applicationprocess.

If my plans change and I do not participate, I withdraw, or I am withdrawn from mystudyabroad program, it is my responsibility to inform the Program Director in writing immediately. I understand that I will be responsible to the program provider for all and any fees due them according to theirpolicies.

I understand and accept that if I have unpaid bills with my program provider, UICmay place a financial hold on my UIC account. I also understand that this can potentiallyprevent me from registering or attending classes and/or filing for graduation atUIC.

I understand and hereby acknowledge that I assume all risks incurred by my participation inthisprogram.

I have carefully read the foregoing Release & Waiver, I know and understand the contents hereof, and Ivoluntarily sign below as an acknowledgement of my acceptance of these terms.

I certify that I am at least 18 years of age and that I have read and fully understood this Waiver and Release.

SignatureDate

Parental Consent (Required ONLY if student is under 18 years at beginning of program)

The undersigned parent or legal guardian of the above-named student, a minor, hereby consents to the participation of said student in this program, certifies that he/she has read and understood the contents of the Release & Waiver and voluntarily signs below as an acknowledgement of the acceptance of the terms hereof.

Parent/GuardianSignatureDate

PrintedName:

1

REQUESTS FOR ACCOMODATIONS

TheCentro Ollinwillprovide reasonable accommodation to qualified individuals with disabilities. The student must understand that not all accommodations are possible at every study abroad site. Many sites, for example, do not have the same infrastructure available to students on their home campus. The student must request specific accommodations in writing (see below). The student must also be registered with the UIC Disability ResourcesCenter.

I do not have any requests.Signature:

I do haverequests.

Please describe your requests in space provided below and provide a letter from the UIC Disability Resource Center supporting these accommodations.

Release of Information Form

I hereby grant permission to the UIC Disability Resources Center to release my Request for Accommodations letter to the UIC Oaxaca Program Director and to my international host institution advisor in order to initiate the planning process for the coordination of accommodations for my chosen study abroad program. Further, I grant permission for the Oaxaca Program Director to speak with my DRC counselor regarding my Request, when necessary for clarity or additional guidance. I understand that any information regarding my disability shall be considered confidential and will only be shared between DRC, the Oaxaca program director, and the host institution, and will only be shared on a need-to-know basis.

Signature:Date:

Name:UIN:

AUTHORIZATION FOR RELEASE OF DISCIPLINARY RECORDS

Study abroad is a special opportunity granted to students who demonstrate responsibility, maturity, and good academic and disciplinary standing. Students who fail to demonstrate these characteristics during theapplication process and/or prior to their departure may not be eligible to enroll for study abroad credit at UIC. In such cases, weretaintherighttonotaccept astudent’sapplication.

As part of your study abroad program application process, we will verify your UIC disciplinary history.

By signing this form, you attest to the following:

The information I have provided on my study abroad program application is true and accurate.

I authorize the Office of the Dean of Students to release records pertaining to my disciplinary history at UIC to the Director of the Oaxaca study abroad program for the purposes set forth above.

I understand that I may be subject to the Student Disciplinary Procedure of the University of Illinois at Chicago and/or the disciplinary procedure of my program sponsor/host institution for the duration of my study abroad program.

I understand that conduct that violates the disciplinary procedures of UIC or of my sponsor/host institution may result in dismissal from the program without academic credit or refund.

Printed nameofapplicantUIN

SignatureofapplicantDate

REQUIRED: APPLICATION ESSAY

Maximum 200 words. Please write this YOURSELF on a computer. You may use a Spanish spellchecker if you wish, but any use of Google Translate will disqualify you from participating in the programbecause we need an honest assessment of your written Spanish.

¿Por qué quieres estudiar en Oaxaca? ¿Qué buscas aprender? Nombra por lo menos dos (2) motivos.

OPTIONAL: SCHOLARSHIP APPLICATION

Maximum 200 words. Please write this YOURSELF on a computer. You may use a Spanish spellchecker if you wish, but any use of Google Translate will disqualify you from being considered for the scholarship.

Si te dan esta beca, ¿de qué manera te gustaría regresar algo a la comunidad?