Southwest Missouri State University

MISSOURI STATE UNIVERSITY 1 RECIPROCAL EXCHANGE PROGRAMS

RECIPROCAL EXCHANGE APPLICATION CHECKLIST

A complete application package for any Missouri State University reciprocal exchange program will

include the following information:

 Student Application  Waiver Form (form inside packet)  Course of Study: Please list the courses which you would prefer to take at your host institution (see host institution’s course catalog), then list several alternative courses you would be willing to take in case your first choices are not available.  Biography: Essay of 250-500 words. Introduce yourself, explaining your strengths and weaknesses, and explain why you are a strong candidate for a study away program. Refer to emotional and intellectual achievements, personal interests, career goals, etc. Germany exchange applicants must submit essays in both English and German; Mexico exchange applicants must submit essays in both English and Spanish.  Statement of purpose: Essay of 200-500 words. Present your reasons for wanting to study abroad in the location you have chosen. Germany exchange applicants must submit essays in both English and German; Mexico exchange applicants must submit essays in both English and Spanish.  Two letters of recommendation (forms inside packet): Recommendations must come from professors who have had you in class (current or past classes).  One language evaluation (form inside packet): Must come from a language professor who has had you in class (Germany and Mexico exchanges only).  Official transcript(s): from Missouri State (including classes currently in progress) and any other institution from which you have received college credit. Have them sent to the office:

The Study Away Office Jim D. Morris Center for Continuing Education, Suite 101 301 S. Jefferson Ave. Springfield, MO 65806

 Art portfolio: In slide format (For students interested in applying for the art program on the Australia exchange to Tasmania only)  $100 deposit: check or money order only; payable to Missouri State University. MISSOURI STATE UNIVERSITY 2 RECIPROCAL EXCHANGE PROGRAMS

STUDENT APPLICATION

PROGRAM (country and host school) ______

TERM (circle one) Fall Spring Academic Year 20_____

NAME ______(Last) (First) (MI)

M-NUMBER______DATE OF BIRTH (dd/mm/yyyy) ______

CITY, STATE, COUNTRY OF BIRTH ______

HRS COMPLETED______CUMULATIVE GPA ______

MAJOR______MINOR______

PRINCIPLE FIELD(S) OF STUDY DURING EXCHANGE ______

PREVIOUS FOREIGN TRAVEL EXPERIENCE (please describe) ______

______

PERMANENT ADDRESS ______

______

LOCAL ADDRESS (if different)______

______

MOST-USED EMAIL ______

MOST-USED PHONE ( _ ) ______

Person(s) to Contact in case of EMERGENCY:

NAME ______Applicant Signature Date ADDRESS______

TELEPHONE______Study Away Advisor Date MISSOURI STATE UNIVERSITY 3 RECIPROCAL EXCHANGE PROGRAMS

RELATIONSHIP TO YOU______

STATEMENT OF RESPONSIBILITY, RELEASE, WAIVER OF LIABILITY & HOLD HARMLESS AGREEMENT

In consideration for receiving permission to participate in a Missouri State University study abroad program, I hereby release , waive, discharge and covenant not to sue Missouri State, its officers, agents, faculty or employees (hereinafter referred to as University) from any and all liability, claims, demands, actions, and causes of actions whatsoever arising out of or related to any loss, damage or injury, including death, that may be sustained by me, or to any property belonging to me, whether caused by the negligence of University, or otherwise, while participating in such course of activity, or while in or upon the premises where such activity is being conducted, or while traveling to or from the place where such program will be taking place.

I am fully aware of and accept the risks of overseas flights, lengthy bus trips and travel by van, including delays and added expense, and the risks of living in a foreign country where laws and the judicial system are different from what I am accustomed to and where penalties may be harsh and constitutional safeguards may not exist. I am fully aware of the risks of acts of crime or terrorism, knowing that these conditions may be hazardous to my personal property and me. I am also aware of all the risks of living and traveling alone in a foreign country, should I purposely or accidentally separate myself from my project group or decide to remain abroad upon the end of this program.

I am fully aware of and accept the risks of unfamiliar diseases existing in foreign countries and the lack of medical attention available under the circumstances, and I am further aware of and accept the risks of available living accommodations, knowing that the same may be hazardous to me and my property, and I voluntarily assume full responsibility for any risks of loss, property damage or personal injury including death that may be sustained by me as a result of being engaged in such activity, whether caused by the negligence of the University or otherwise. And, I am fully aware of the risks to which I will subject myself and my property, should I decide to remain abroad beyond the time that the program has come to an end, especially the risks of remaining there alone, without faculty advisors or University sponsorship.

I agree to indemnify myself and hold harmless the University and covenant not to sue University for any loss, liability, damage or costs, including attorney’s fees, that University may incur due to my participation in this program, whether caused by University’s negligence or otherwise.

It is my express intent that this release, waiver, and hold harmless agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representatives, if I am deceased. I further agree that this document shall be construed in accordance with the laws of the State of Missouri.

I certify that I have health care coverage (and will continue to have such coverage throughout the length of this program) which covers illnesses or injury suffered while on an off campus program or trip. I agree that I am solely responsible for any costs for medical care not covered by my health insurance.

I certify that I have no physical or medical condition that will impact my participation in the study abroad program or that I have disclosed any physical or medical condition which may require special medical attention or accommodation in writing to the director of the study away program.

I understand and acknowledge that the University may change the program including the itinerary, travel arrangements or accommodations at any time for any reason and that the University will not be responsible for any resulting losses or expenses.

I understand and acknowledge that the University has the right to expel any student from the program in its sole discretion should it deem the student’s behavior impedes or obstructs the program.

I understand and acknowledge that the University, in its sole discretion, has the right to cancel this program at any time and to require all participants to return to the United States, if it determines that conditions in the host country pose a heightened potential of danger to the participants.

In signing this agreement and release, I acknowledge and represent that I have read the entire agreement, understand it, and sign it voluntarily as my own free act and deed, and no oral representation, statements or inducements, apart MISSOURI STATE UNIVERSITY 4 RECIPROCAL EXCHANGE PROGRAMS from the foregoing written agreement have been made, that I am at least eighteen (18) years of age and fully competent, and that I execute this agreement and release for full, adequate and complete consideration fully intending to bound by the same.

In witness whereof, I have hereunto set my hand and seal this _____ day of ______, 20__.

______Applicant Signature Date Print Name MISSOURI STATE UNIVERSITY 5 RECIPROCAL EXCHANGE PROGRAMS

ACADEMIC REFERENCE FORM

To Be Completed by the Applicant:

NAME OF APPLICANT______

NAME OF PROGRAM ______

REFERENCE REQUESTED FROM ______

To the applicant: under the U.S federal law (Section 438 of Public Law 90-247), students are permitted access to certain educational records. Section 438(a) (2) (B) provides that a student may waive the right to inspect confidential letters of recommendation. Many applicants have found that recommendation letters may have a greater effect when such letters are written in confidence. If you waive your right to inspect the information requested by this form, please sign below.

______Applicant Signature Date To be completed by the Referee: To the referee: The student above is applying for study abroad through a Missouri State University reciprocal exchange program, as indicated. Since participants serve as representatives of the U.S. and Missouri State University, we are concerned with both academic excellence and personal suitability of applicants to study abroad. The willingness of host institutions to accept future participants will be affected by the candidate’s performance.

How long and in what capacity have you known the applicant? ______

Please indicate the applicant’s ability and academic competence in comparison with other individuals whom you have known at similar stages in their academic careers. Inadequate Above Below Outstanding Average Opportunity Average Average to Observe Knowledge in area of specialization Motivation and seriousness of purpose Ability to plan and carry out research/ independent study Ability to express thoughts in speech and writing Emotional stability and maturity Self-reliance and independence MISSOURI STATE UNIVERSITY 6 RECIPROCAL EXCHANGE PROGRAMS

Academic Reference form, page 2 Please print legibly in the area below or attach a printed statement.

Please comment specifically on the applicant in terms of the following: (a): Academic suitability for study at an institution abroad; (b): Personal suitability for living abroad; (c): How participation in this exchange program will be of benefit, both academically and personally; (d): Weaknesses; (e): Linguistic preparation, if applicable; (f): Any other factors which you believe may affect a successful experience on a foreign exchange.

______Referee Signature Date

______Name (please type or print) Position or title

______Office address

______Office phone E-mail address

Please return form to The Study Away Office the Study Away Office by Jim D. Morris Center, Suite 101 Phone: 836-6368 Fax: 836-6146 [email protected] MISSOURI STATE UNIVERSITY 7 RECIPROCAL EXCHANGE PROGRAMS

ACADEMIC REFERENCE FORM

To Be Completed by the Applicant:

NAME OF APPLICANT______

NAME OF PROGRAM ______

REFERENCE REQUESTED FROM ______

How long and in what capacity have you known the applicant? ______

Academic Reference form, page 2 Please print legibly in the area below or attach a printed statement.

______Referee Signature Date

______Name (please type or print) Position or title

______Office address

______Office phone E-mail address

Please return form to The Study Away Office the Study Away Office by Jim D. Morris Center, Suite 101 Phone: 836-6368 Fax: 836-6146 [email protected] MISSOURI STATE UNIVERSITY 9 RECIPROCAL EXCHANGE PROGRAMS LANGUAGE PROFICIENCY REPORT

To Be Completed by the Applicant:

NAME OF APPLICANT______

NAME OF PROGRAM ______

LANGUAGE ______What coursework have you pursued in or related to the required language? Include courses in progress, and list name of course, brief description and grade received. What other experiences have you had in the required language (i.e. spoken at home, travel, reading, etc.)?

To be Completed by a Professional Language Instructor: To the Instructor: Exchange participants matriculate directly in to the host institution and should be able to follow university lectures in the foreign language, participate in seminar discussions, take notes and understand written material in their field. The willingness of the host institution to accept future MISSOURI STATE UNIVERSITY students will be determined by the performance of the candidates selected. Your opinion of the applicant will be of great assistance in the selection process. It is important that your comments be detailed and frank. Please complete both pages. Thank you for your assistance.

1. Please note your opinion of the applicant’s present language ability in each of the following categories.

AURAL COMPREHENSION ___ None ___ Limited to slow, uncomplicated sentences ___ Understands simple conversation ___ Understands conversation on simple academic topics ___ Understands sophisticated discussion of academic topics

SPEAKING ABILITY ___ None ___ Able to complete structurally simple, short phrases ___ Uses basic grammatical structure, speaking with limited vocabulary ___ Uses structural patterns, but not with consistent accuracy; adequate to participate in conversational

topics ___ Has control over structural patterns; can handle a wide range of conversational situations MISSOURI STATE UNIVERSITY 10 RECIPROCAL EXCHANGE PROGRAMS

Language proficiency report, page 2. READING ABILITY ___ None ___ Limited to simple vocabulary and sentence structure ___ Understands conversational topics and non-technical subjects ___ Understands materials which contain idioms and specialized terminology ___ Understands sophisticated materials, including those in proposed field of study

WRITING ABILITY ___ None ___ Writes simple sentences on conventional topics, with some errors in spelling and structure ___ Writes on academic topics with few errors in structure and spelling ___ Writes with idiomatic ease of expression and feeling for the style of the language

2. What is your opinion of the applicant’s ability to pursue university-level coursework in this language? ___ Should have no difficulty ___ Should be able to manage adequately after a short period of adjustment abroad ___ Will require additional training before beginning the exchange ___ Will require considerable training before necessary competence can be attained

3. How was the evaluation determined? ___ Based on knowledge of applicant’s coursework in language at MISSOURI STATE UNIVERSITY ___ Written examination ___ Name of test and date administered ______Oral examination. Date administered ______

4. Please add any additional comments relating to the applicant’s linguistic ability.

5. Please mark as appropriate: ___ I unconditionally approve the applicant for study abroad in this language. ___ I approve the applicant for study abroad in this language with the following conditions:______I do not approve the applicant for study abroad in this language.

______Instructor’s Signature Date Name (please type or print)

______Position or title Office address ______Office phone E-mail address The Study Away Office Please return form to Jim D. Morris Center, Suite 101 the Study Away Office by Phone: 836-6368 Fax: 836-6146 [email protected] ______