Department of French
Rutgers Academic Building
School of Arts and Sciences
Rutgers, The State University of New Jersey
15 Seminary Place, 4th Floor
New Brunswick, New Jersey 08901-1414
http://french.rutgers.edu
[email protected]
732-932-8223
Fax: 732-932-7125
Rutgers Summer in Paris Program
Application for Admission
Your file is activated by submission of the application, but your file cannot be considered for admission until all of the
necessary documents have been received by the Department. Please return the application and forms to the address above.
*An official academic transcript is required for non-Rutgers students only*
Please Print Legibly
Name _____________________________________
Last
First
____________________________
Student E-mail address
Home Address ___________________________________________________________
Street
City
State
Zip
______________________
Student Cell Phone #
______________________
Student Home Phone #
***Address (if different from above) where you would like your mail to be sent to during school:
___________________________________________________________________________________________________
Date of Birth ____________________________
RU ID # ___________________________
Are you a Douglass College Residential Student:
Yes
No
Country of Citizenship*_____________________
*If you are not a USA citizen, please be sure to inquire about possible VISA documentation needed for travel to
Paris. Contact your nearest French Consulate.
Schools attended (secondary, college and university) with school most recently attended listed first:
Institution
Location
Dates of Attendance
_______________________________
____________________________
__________________________
_______________________________
____________________________
__________________________
_______________________________
____________________________
__________________________
_______________________________
____________________________
__________________________
Preparation in French (Number of years) High School: _____________________
Course Title & Description
College: ________________________
Semester Taken
Grade Received
___________________________________________________
_________________________
_________________
___________________________________________________
_________________________
_________________
___________________________________________________
_________________________
_________________
___________________________________________________
_________________________
_________________
Rutgers Summer in Paris Program
Application for Admission - Page 2
French courses that will be completed by Spring semester: ____________________________________________________
Additional experience with French language and civilization, if any: ______________________________________________
PERSON TO CONTACT in case of emergency:
Name _____________________________________________
Relationship to applicant _________________________
Address ____________________________________________________________________________________________
Street
City
State
Zip
Telephone numbers: Work ________________
As of now, what courses would you take?
Home __________________
PLEASE CHOOSE TWO COURSES
Cell ________________________
(You can change your mind later.)
Intensive Advanced Grammar 213
Topics in French Cinema: Beyond the Fiction Feature Film 372
Aspects of French Literature 215
Modern France 405*
Culture, Conversation, and Composition 303
French Food: Cultural Identity in a Global Context 469*
*open to students having completed at least two 200-level courses or equivalent
How did you hear about the Rutgers Summer in Paris Program? ______________________________________________
Date ___________________________
Signature ______________________________________________________
This application must be completed by submission of:
1.
2.
3.
4.
A Letter of recommendation from a French Teacher (Form 1)
A Medical report (Form 2)
A Responsibility statement with signatures (Form 3)
An official academic transcript (if you are a non-Rutgers student)
Return application and all forms to:
Director, RUTGERS SUMMER IN PARIS PROGRAM
Department of French
Rutgers Academic Building
Rutgers, The State University of New Jersey
15 Seminary Place, 4th Floor
New Brunswick, NJ 08901-1414
Department of French
Rutgers Academic Building
School of Arts and Sciences
Rutgers, The State University of New Jersey
15 Seminary Place, 4th Floor
New Brunswick, New Jersey 08901-1414
http://french.rutgers.edu
[email protected]
732-932-8223
Fax: 732-932-7125
Rutgers Summer in Paris Program
To:
A Teacher of French
From: Director, Rutgers Summer Program in Paris
Form 1
(Recommendation from
Teacher of French)
Name of Applicant ___________________________________________________________________________________
First
M.I.
Last
French Course
The person named above is applying for admission to the Rutgers Summer in Paris Program. We would appreciate your
confidential evaluation of the applicant's (a) intellectual ability (b) emotional maturity, and (c) linguistic competence for
successful participation in the program.
Signature _______________________________________________________
Date ___________________________
Printed Name and Title________________________________________________________________________________
Address ___________________________________________________________________________________________
Please return the completed form to the above address as soon as possible. Admissions to the program will be
decided as applications are completed. We thank you for your assistance.
Department of French
Rutgers Academic Building
School of Arts and Sciences
Rutgers, The State University of New Jersey
15 Seminary Place, 4th Floor
New Brunswick, New Jersey 08901-1414
http://french.rutgers.edu
[email protected]
732-932-8223
Fax: 732-932-87125
Rutgers Summer in Paris Program
Form 2 (Physician Form
Please have your medical provider answer the following questions and sign and date below:
NAME: FIRST___________________________
LAST_____________________________________
This student has been accepted into the Rutgers Summer in Paris Program. In the interest of the student’s safe and
successful participation, we would appreciate your cooperation in answering the following questions and adding any
information that you feel is relevant to the student’s ability to participate in the study abroad program. This information will
remain confidential and will be provided only to the Rutgers Summer in Paris Program in New Brunswick, the onsite
Program Director, and those with a need to know for the purpose of providing any necessary accommodations or in the event
that medical attention is necessary.
State of General Health: Good ____________
Fair ____________
Age ____________
Weight ____________
Height ____________
Poor ____________
1. Does the applicant have any physical disability?
yes
no
2. Has the applicant been treated for mental disorder or emotional disturbance within the last five years? yes
no
3. Does the applicant have any dietary restrictions or known allergies (e.g., food, medication, etc.) that the program should
be aware of in the event of an emergency?
yes
no
If yes, please describe below (including information about the severity of the allergy).
1. Is the student taking any medications, or will the student be taking any medications while abroad, that the program should
be aware of in the event of an emergency? (Please note that the availability of medications varies by country and this should
be researched before going abroad).
yes
no
If yes, please list the medications and describe what they are used for. (Please attach additional sheets if necessary)
5. Are all routine immunizations up to date?
yes
no
6. Is the student currently being treated, or has the student been previously treated for any chronic or serious medical
condition (e.g., diabetes, asthma, congenital disorder, cancer, eating disorder, psychiatric illness, etc.)?
If yes, please describe below and include any ongoing treatment that the student is receiving and may need to continue while
abroad. (Please attach additional sheets if necessary.)
7. Have you any further medical data that should be known to the Director of the program?
yes
no
8. Does the student require accommodations to a disability to enable her/him to participate in this program?
yes
If yes, please describe below. (Please attach additional sheets if necessary)
no
Foreign travel and study abroad necessarily involve stress due to exposure to different cultural and physical
environments, as well as the potential for possible experience with a medical and healthcare situation different from
that found at home. Is there any additional information that would be helpful for the program to be aware of during
this student’s study abroad experience (please check the relevant box)?
No medical contraindications were identified during this examination that precludes this student from participation in
the study abroad program.
No medical contraindications were identified during this examination that precludes this student from participation in
the study abroad program. However, based on the student’s disclosed history and today’s physical exam, further evaluation
through CAPS or an outside mental health/counselling provider is required to evaluate this student’s ability to safely and
successfully travel abroad.
Doctor’s Name (print) __________________________________________________
Date _______________________
Address ____________________________________________________________________________________________
City _____________________________________________
State __________________
Zip ___________________
Signature _____________________________________________________Phone: ________________________________
Please mail or fax completed form to:
Department of French
Rutgers Academic Building
Rutgers, The State University of New Jersey
15 Seminary Place, 4th Floor
New Brunswick, New Jersey 08901-1414
Phone: 732-932-8223
Fax: 732-932-7125
Department of French
Rutgers Academic Building
School of Arts and Sciences
Rutgers, The State University of New Jersey
15 Seminary Place, 4th Floor
New Brunswick, New Jersey 08901-1414
http://french.rutgers.edu
[email protected]
732-932-8223
Fax: 732-932-7125
Rutgers Summer in Paris Program
Form 3
Responsibility Form
Responsibility Statement
It is important that all students participating in a Rutgers Program Abroad, including the Rutgers Summer in Paris
Program, and their parents (if under 18) sign and return the following statement.
I understand that:
1. The participant in the Rutgers Summer in Paris Program is personally responsible for complying with all
regulations and laws of the host educational institutions, resident accommodations and of the host country
itself.
2. The program can assure no protection to the student or his/her family on the occasion of an infringement of
law. The student should be especially aware of the sensitivity of the local authority to the abuse of drugs and
alcohol among its students and their tendency to deal severely with offenders.)
3. If the student's behavior is at any time evaluated as damaging to the welfare of the group or the program as a
whole, Rutgers reserves the right, in its sole discretion, to drop the student from the program.
2. Participation in the Rutgers Summer in Paris Program, as in any study abroad program, obviously involves
travel to and living in a foreign country. Participation in the program involves the normal risks of travel, including
crime, natural disaster, as well as exposure to possibly volatile or uncertain political situations, including
unpredictable acts of violence (often directed at Americans) that have received much public attention over the
last few years. Rutgers can assume no responsibility for the risks inherent in travel and living abroad.
3. The Rutgers Summer in Paris Program accepts no responsibility for personal property which must be insured
separately if so desired and reserves the right to make any changes necessitated by circumstances.
4. It should also be clear that the program does not require permission, but requests notification to the office
of the Director whenever the student intends to be absent for more than 24 hours, in order to ensure the
effective handling of routine or emergency communications.
5. Language Pledge – One of the goals of the Summer in Paris program is to immerse students in the French
language. For this reason, you will be asked to pledge to speak only French during the entire length of the
program.
SIGNED:
Applicant:
____________________________
Date: ______________________________________