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
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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:
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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.
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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
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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.
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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
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