International Short Term Program Application Form Applicants will be selected on the basis of their academic merit and other supporting information requested on this form Name of Applicant Program Title Program Dates Host Faculty PRIVACY STATEMENT The personal information you provide in this form is governed by the Privacy and Personal Information Protection Act 1998, the Health Records and Information Privacy Act 2002 and CSU’s Privacy Management Plan (the Privacy Legislation). Your information will be collected by CSU Global to assess whether you are a suitable student to send overseas to a host institution and to assess you for any travel or scholarship grants. If you are accepted into the CSU Global Exchange Program, your information may be disclosed to authorised personnel at a host institution to assess your eligibility to secure a place at that host institution. Your personal information will not otherwise be made available to any other person or organisation for any other purpose without your consent except where CSU may be legally required to do so. The provision of personal information in this form by you is voluntary but if this information is not provided, CSU Global may not be able to assess your application in a timely manner. You have a right of access to, and correction of, your personal and health information in accordance with the Privacy Legislation. Please direct any enquiries you may have in relation to this matter to CSU Global. If you are unhappy with the way CSU has handled or failed to handle your personal information, you may apply to have the matter reviewed by lodging a complaint with the CSU Ombudsman. I understand and acknowledge the information above. Signature: . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . . . . dd/mm/y PERSONAL DETAILS Title: Other Middle name/s: First Name: Last Name: Name as it appears on your passport: I have a current passport: Yes If yes, is it an Australian passport No OR I am now applying for a passport: Please note this process may take 4-6 weeks If no, please state country of issue CSU Global Short Term Program application Page 1 of 6 You must have a valid passport 3 months Passport Issue date: prior to the commencement of the program. No My passport is valid for a minimum of 6 months from the program return date: Yes Passport Expiry date: If you answer ‘no’ you will be required to apply for a new passport. *Please include a photocopy of the photo page of your passport with this application* Student Number: Email: Session phone number: Mobile Number: Session address: State in which you are enrolled to vote?(for visa purposes) Date of Birth: Country of citizenship: dd/mm/yy Permanent resident of Australia: □ Yes □ No Are you an international student? □ Yes □ No * Please provide a copy of residency/student visa I NT E R N A T I O NA L S H O RT T E R M P RO G R A M D E T A I LS Applicant’s current CSU course title: (including major if applicable) Applicant’s Faculty: Applicant’s School: Campus: I am studying: Year of course commencement at CSU: □ Full-time □ Part-time □ Internal □ Distance Education Scheduled dates and duration of program: From: (DD/MM/YY) to(DD/MM/YY) How did you hear about this program? (please tick) lecture visit CSU Global website Total days promotional display newsletter academic staff Facebook Twitter previous participant other (please specify) EMERGENCY forum posting CONTACT DETAILS I appoint the following person my designated Emergency Contact and authorise CSU and/or the host institution to contact the person for or with information about me if a need arises. I have fully informed my Emergency Contact regarding all aspects of my International Short Term Program, including the nature of possible risks. This emergency contact arrangement is valid from the date of my signature on this application until completion of the exchange program I am accepted into. Title: First Name: Middle name/s: Primary Contact Number: : Secondary Contact Number: CSU Global Short Term Program application Last Name: Email: Page 2 of 6 Emergency Contact Home address: S P E C I AL A S S I S T A N C E - P AR T I CI P AN T S C H A L L E N G I N G A C T I V I T I ES M A Y B E R E Q UI R E D T O M A N A G E P H Y S I C A L L Y , S U C H A S , B UT N O T L I M I T ED TO : CA R R Y I N G O W N L U G G A GE , W A L K I N G L O N G D I S T A N C E S A N D S T A N D I N G F O R L ON G P E R I OD S OF T I M E Will you require any special assistance (e.g. disabilities, illnesses, allergies) during the program? (Please note: travel insurance may not cover some situations, including pre-existing medical conditions. Providing this information can assist in ensuring necessary coverage) □ Yes □ No It is the responsibility of the applicant to research the level of services and facilities they may require in their destination country. It is also the responsibility of the applicant to confirm the suitability of insurance coverage for pre-existing conditions or special circumstances. If you answered yes, please describe what assistance you will need. STATEMENT OF P U RP O S E a) In approximately 100 words please outline your reasons for wanting to join this program including how you feel the program will benefit you academically and personally. CSU Global Short Term Program application Page 3 of 6 b) In approximately 100 words please outline how you feel your participation in the program will benefit other participants and the success of the program. ACADEMIC TRANSCRIPT Please attach a copy of your academic transcript to this application. Your academic performance within your course or individual subjects will be considered as part of the application process. A photocopy is fine - you do not need to provide a certified copy. MEDIA RELEASE AGREEMENT I understand that my testimonials/quotes and/or video footage/photographic images taken of me while on this international program are for free and unrestricted use by Charles Sturt University and its agents in editorial, advertising, educational and promotional material. I understand that international copyright and intellectual property rights on these materials will remain the property of Charles Sturt University who will be entitled to broadcast, publish or otherwise distribute these materials and any product thereof in any way or manner that they see fit, in perpetuity. My signature below signifies my approval, and I therefore have no further claims for compensation from Charles Sturt University or its agents. Student’s name: Student number: Student’s signature: DO NOT TYPE NAME Date: Please note: If selected for this program, you will be requested to complete a program evaluation and required to complete pre-departure modules. Recipients of the Vice Chancellor Travel Grant will be required to assist the Faculty and/or CSU Global with future promotional activities. PROGRAM CREDIT Further inquiries regarding academic content and recognition for this program should be referred to the academic program manager CSU Global Short Term Program application Page 4 of 6 S T UD EN T A C K N O W L E D G E M E N T , D E C L AR A T I O N AN D A G R EE M EN T By inserting a against each of the following statements and signing where indicated, you confirm your understanding and acceptance of the acknowledgements, declarations and agreements set out below and that CSU may rely on and enforce these acknowledgements, declarations and agreements. My Application I declare that all the information submitted on this application is correct and complete. I understand that the provision of false or misleading information may result in non-acceptance of this application or immediate expulsion from the CSU Global Program. I understand that the decision of CSU Global is final with respect to the preliminary acceptance into the CSU Global Program. I agree to advise CSU Global if there are any changes to the information I have given in this application. My privacy I acknowledge that I have read the Privacy Statement on the first page. I consent to the collection of my personal information contained in this application by CSU Global and, subject to my acceptance into CSU’s Global Program, to the disclosure of such information to a partner for the purpose of assessing my eligibility for a place in the program. I consent to CSU Global disclosing my personal information to the host institution, my designated Emergency Contact and any Australian or foreign government agencies, for any purpose related to the protection of my safety and welfare. I consent to the distribution of my personal and contact details to CSU divisions, external organizations and Government departments in relation to this program. Please note if you are a participant in a government funded program part of the funding agreement is that your personal details will be released to this body. My safety I acknowledge that CSU does not warrant that the host country is a safe and suitable country for overseas travel and that my decision to travel to a particular country or region is a personal one. I acknowledge that I am required to register my travel online at http://www.smartraveller.gov.au/ and Travel Tracker to keep myself updated with the latest travel advice from this website. I acknowledge that I am required to undertake the CSU Global Pre-Departure modules and agree to follow any relevant directive issued by the Australian Embassy or High Commission or other Australian Government representative in the host country I understand that CSU can require my withdrawal from the program should it deem political instability and/or terrorist activities in the region to be unsafe for me to remain in my host country. My participation in CSU Global Program I understand and accept that I must comply with the academic rules and regulations in place at the host institution and the laws applicable in the host country at all times and that any failure to do so may result in my exclusion from the host institution or expulsion from the host country at my own cost. I understand that I am bound by, and must comply with, the CSU Academic and Student General Misconduct Rule at all times during my exchange. I will not participate in any activity, including political activity, which might endanger either CSU or the host institution, or undermine the effectiveness or viability of the program. CSU Global Short Term Program application Page 5 of 6 I understand that CSU Global can require my withdrawal from the program for conduct unbecoming of a student of CSU, and will be sole authority in exercising this judgement. I understand that it is my responsibility to negotiate and obtain approval from CSU for obtaining academic credit for study. My financial obligations I understand that my participation in this exchange program and associated travel is my sole responsibility and I assume all financial responsibility, including debt, arising from such circumstance. I am aware of the likely living cost of my stay overseas, and I have the necessary financial capacity to meet such costs for the full duration of my program. I understand the costs for which I am responsible for in association with this program and I understand that I am liable for CSU subject tuition fees and other CSU costs while I am on this program. I agree that I am responsible to ensure that my travel and medical insurance covers me for the total period of my travel including any independent travel before, after and during the exchange program. My liabilities I agree to indemnify CSU for any expenses, losses, damages and costs that I may sustain or incur as a result, whether directly or indirectly, of any action arising from any failure by myself to obtain or maintain travel and medical insurance coverage. I understand that compulsory health insurance may be mandatory at my host institution. This may be in addition to the coverage I have purchased prior to departure. I agree that CSU and its staff are not to be held accountable for any injury or loss I may suffer when I am acting or travelling independently before, after and during the program. I understand that CSU will not be liable in any way for injury, sickness or damage that I may suffer during my participation in the program and/or resulting from the travel arrangements and any other related or incidental activities during this program. General I have sought and obtained appropriate advice on my responsibilities as set out in this Acknowledgement, Declaration and Agreement. I understand that this Acknowledgement, Declaration and Agreement cannot be modified or amended except in writing by CSU. Signature: . . . . . . . . . . . . . . . . . . . . . . . . . Date: . . . . . . . . . . . . . . . . . dd/mm/yy DO NOT TYPE NAME CSU Global Short Term Program application Page 6 of 6
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