Study Abroad Application Vietnam and Cambodia Summer 2017

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1 Study Abroad Application Vietnam and Cambodia Summer 2017 Program: COM 220: Storytelling Then and Now Vietnam and Cambodia Course Dates: 5/24/17 7/20/17; Trip Dates 6/16/17 7/3/17 Information meetings will be held in October, 2016 and January, 2017 Colorado Mountain College Attn: Stephanie Glaser County Road 319 PO Box 897 Buena Vista, CO (719) Name (same as on passport): Address: City: State: Zip: Cell phone: Home phone: address: Social Security Number: Date of Birth:

2 Passport #: Current CMC Student? Yes / No Previous CMC Coursework? Yes / No CMC Program: Dates: Emergency Contact (list names and relationship:) Emergency Contact Address: Phone: Doctor s Name: Doctor s Phone: Doctor s Address: Do you have or have you had any medical condition(s) of which we should be aware (please consider family medical history)? Yes / No If yes, please explain

3 Do you require special services or accommodations for any disability (including physical, medical or psychological? Yes / No If yes, please explain Are you taking any medications? Yes / No If yes, please list name(s) of medications and dosage: Do you have any allergies? Yes / No If yes, please explain: Do you smoke? Yes / No List any medical, religious or personal restrictions regarding food, diet or activities In what medium to you prefer telling a story? (e.g. writing, poetry, painting, photography, video, music, songwriting, sketching, sculpture etc.) How did you hear about our program?

4 Please read VERY IMPORTANT: I have supplied accurate information that was requested above. I understand that proof of health insurance (with international coverage) will be required by due date (discussed during pre-trip meetings). I understand that I need to be self-reliant, independent and able to take care of myself during travel, physical activities and study. Further, I understand that if my behavior is disruptive or inappropriate at any time during the study abroad trip, I will be sent home at my own expense. Participant Signature: Date: If student is under 18 years of age at the time of application, the student s parent or court-appointed guardian must sign this application. Guardian Signature: Print Guardian Name: Date: Application is due by

5 Payment Information: A $1,100 deposit* is required with your completed application, which can be paid either by check or credit card (see below). The remaining balance of $1,100 will be due by March 15, We recommend that you apply early as there are a limited number of openings. Payment by Check: Please make checks out to Colorado Mountain College and send in with this application. Payment by Credit Card (CMC does not accept American Express): Credit Card Number: Name on Card: Expiration Date: Security Code (3-digit number on back of card) Billing Address: City: State: Zip: Amount charged with this application $1,100 $2,200 Signature: Date: *100 percent of this payment is non-refundable except under specific circumstances agreed to by Colorado Mountain College. CMC reserves the right to alter or cancel any program arrangements as conditions warrant. Program fee $2,200 The program fee includes: All lodging Homestay in Dai Binh, Domestic travel both ground and air in Vietnam and Cambodia Course activities Local guides 85-90% of meals Bottled water for all excursions Limited travel insurance through CMC

6 The program fee does not include: Round trip airfare to Southeast Asia Some meals Vaccinations Passport and visa fees CMC tuition Spending money, Phone calls Travel and trip cancellation insurance. Note: If students are not able to be at Hanoi s Noi Bai International Airport (IATA: HAN, ICAO: VVNB) by the designated pick up times, they will need to pay for transportation to the Hanoi Hotel. CMC Registration and Tuition Students must register for COM 220 (3 credits) through CMC. Tuition is paid separately from the program fee upon registration. Students auditing the class must also register for COM 220. Students may audit the course. In-District: $186 CMC Service Area: $369 In-State: $381; Out-of-state: $1,119 Written paragraph required for all applicants: Write at least one paragraph (or more) stating the reasons why you would like to be accepted into the study abroad program and submit it with this application. If under the age of 18, please have a teacher or counselor write a letter of support. Send all written correspondence, checks and applications directly to: Colorado Mountain College Attn: Stephanie Glaser County Road 319 PO Box 897 Buena Vista, CO (719) (719) (cell)

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