LINCOLN MEMORIAL UNIVERSITY SUMMER 2015 ENGLISH IMMERSION PROGRAM APPLICATION PACKET

LINCOLN MEMORIAL UNIVERSITY SUMMER 2015 ENGLISH IMMERSION PROGRAM APPLICATION PACKET Application Deadlines: The deadline for receipt of this applicat...
Author: Albert Sherman
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LINCOLN MEMORIAL UNIVERSITY SUMMER 2015 ENGLISH IMMERSION PROGRAM APPLICATION PACKET

Application Deadlines: The deadline for receipt of this application and the required $450 deposit is April 13, 2015. The deadline for receipt of full payment for all group participants is June 14, 2015. All travel documents, including copies of students’ passports, visas and tickets (showing both arrival and departure flights) must also be received by June 14, 2015.

Cancellations and Refunds: Until June 14, all program fee funds are refunded except the deposit of $450, which will serve as a cancellation fee. After June 14, 2015 there is no refund.

APPLICATION LINCOLN MEMORIAL UNIVERSITY SUMMER 2015 ENGLISH IMMERSION PROGRAM JULY 12 – AUGUST 1, 2015 Personal Information:

Date:__________________

Name as it appears on your passport:__________________________________________ Date of Birth:_______________ Current school: _______________________________ Location of current school:___________________________ Highest level of education completed: ________________________________ TOEFL score (if available): ___________________ Major in college/university (if available): ________________ Home Address:__________________________________________________ City: ___________________________________

Postal Code: _________

Country:________________________________________ Home Phone: ___________________________

Cell Phone:_____________________

E-mail address (please print carefully): :_____________________________________

Passport Number:_______________________ Expiration Date:__________________ (Passport cannot expire before February 2, 2015) Visa Number:_______________________ Expiration Date:__________________ Emergency Contact: In case of emergency, please list the name and contact information of someone you would like for us to notify. ________________________________ Contact Name

_______________________________ Relationship to Participant

________________________________ Home Phone

_______________________________ Work/Cell Phone

Purpose of Participation -- Writing/Self Introduction 1. Please write a short autobiography (75-150 words)

2. Choose one: a.) Write about your biggest accomplishment. (150-200 words) b.) Write about one big challenge you have faced. (150-200 words)

3. How will studying English at LMU this summer help you meet academic, professional and personal goals? (75-150 words)

English Level – Self Evaluation How well do you know English? Please indicate your level:

Reading No English

Beginner

Low Intermediate

High Intermediate

Advanced

Beginner

Low Intermediate

High Intermediate

Advanced

Beginner

Low Intermediate

High Intermediate

Advanced

Beginner

Low Intermediate

High Intermediate

Advanced

Writing No English

Speaking No English

Listening No English

PARTICIPANT RELEASE FORM I, ____________________________________ (please print) , am participating in the Lincoln Memorial University Summer 2015 English Immersion Program. I understand that as visitor in the United States that I will be subject to the local, state and federal laws of this country. I agree to conduct myself in a manner that will comply with the regulations of Lincoln Memorial University and the English Immersion Program. I further understand that I am solely responsible for any and all costs arising out of my voluntary or involuntary withdrawal from the program prior to its completion. In consideration of being afforded this opportunity to participate in this English Immersion Program, I, for myself, my heirs, successors or assigns, hereby release and hold harmless the Lincoln Memorial University, its Board of Trustees, agents, servants and employees, from any and all claims, demands, causes of action or damages which may accrue on account of bodily or personal injury, property damage or death arising out of my participation in the program, including damages, injury or death arising from the negligence of the aforesaid parties. I am knowledgeable of the possible dangers in traveling to and residing in the United States, such as: terrorism, hijacking, kidnapping, or death. I, for myself, my heirs, successors or assigns, hereby assume any and all risks attendant to this English Immersion Program at Lincoln Memorial University described herein. I understand that I am responsible for any expenses incurred for medical treatment in the event of an injury or accident. _________________________________________ Signature

_______________________________ Date

_________________________________________ Guardian (if participant is less than 21 years of age)

_______________________________ Date

_________________________________________ Witness

_______________________________ Date

PHYSICAL EXAM – TO BE COMPLETED BY PHYSICIAN Instructions to Physician: The above individual is considering participating in the LMU English Immersion Program. The new environment each student faces while participating in the program may challenge his/her physical and mental capabilities to the fullest. Therefore, it is imperative, as a safeguard to the health of the participant, that this report be as complete and accurate as possible. To be completed by Physician I have examined ______________________________________, read their completed “Health Disclosure Form”, and believe that (please indicate one of the following :) ______ He/she is physically qualified to participate in a travel program to Harrogate, Tennessee. He/she presents no evidence of communicable disease, of overfatigue, or any other condition which would affect the quality of his/her academic performance or experience. ______ He/she has indicated a condition as stated on the “Health Disclosure Form.” I have discussed this condition with the participant and do NOT approve travel and residency abroad at this time. ______ He/she has indicated a condition as stated on the “Health Disclosure Form.” I have discussed this condition with the participant and give conditional approval for travel and residency abroad with the following stipulations: __________________________________________________________________________ _________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ In addition to the above, I also certify that I am a licensed medical physician, physician’s assistant, or family nurse practitioner. Physician Signature: ____________________________________Date: ______________ Physician’s Name: _______________________________________________________ Street Address: _________________________________________________________ City, State, Zip Code: ____________________________________________________ Telephone: _____________________________________________________________

Health Disclosure Form Participant’s Name:________________________________ Date:______________________ The following medical information, can be very useful in the event of serious illness or accident. Please complete this form accurately and truthfully. This information will be kept confidential and used only to help Lincoln Memorial University staff respond to a serious injury or illness. Failure to voluntarily disclose accurate and complete information could compound the seriousness of an accident or illness, particularly if your condition prevents you from responding to medical personnel. Though a travel abroad experience can be exciting and rewarding, it can also be both physically and emotionally demanding. Therefore we ask that you provide a candid, truthful evaluation of your health. A certain amount of stress due to culture shock or the change in living conditions and facilities is a normal part of the travel abroad experience. However, in some cases, such stress may aggravate disabilities or illnesses that you have under control at home. With this form, we hope to create an awareness of any health issues that you should take into consideration before going abroad. Instructions: Please answer the questions below. During your physician examination, please have him or her initial at the bottom of this form. Do you have allergies to medication, plants, food, animals, insect stings, etc.?

Yes

No

If so, please explain ________________________________________________ Do you have any physical limitations or disabilities?

Yes

No

If so, please explain ________________________________________________ Have you ever had a major illness?

Yes

No

If so, please explain ________________________________________________ Have you ever had a major surgical operation

Yes

No

If so, please explain ________________________________________________ Have you ever been hospitalized?

Yes

No

If so, please explain ________________________________________________ Have you ever received treatment for drug addiction?

Yes

No

Have you ever been treated by a psychiatrist or psychologist? If so, are you currently receiving treatment?

Yes

Yes

No

No

Do you have any health conditions affecting your physical health?

Yes

No

If so, please explain__________________________________________ Do you currently receive treatment or take prescriptions on a regular basis?

Yes

No

If so, please explain___________________________________________ Do you have any dietary restrictions? Yes No If so, please explain___________________________________________ Participant’s Signature:_______________________ Physician’s Signature:_________________________

ABOUT Lincoln Memorial University Lincoln Memorial University (LMU) is a values-based learning community dedicated to providing educational experiences in the liberal arts and professional studies. LMU’s main campus and 11 extended learning sites are located in the Appalachian region of east Tennessee and southeast Kentucky. The University serves a diverse student body of 4550 students from 45 states and 21 foreign countries. LMU offers a relevant curriculum for the 21st century in over 30 areas of study including business, arts and humanities, sciences and mathematics, education and health professions. Graduate and professional programs are available in education, nursing, physician assistant studies, jurisprudence, veterinary medicine and osteopathic medicine.

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