Personal Data:

Name __________________________________________________________________

Social Security number ____-___-_____ Country of citizenship _________________

School address ___________________________________ Box # __________________

School telephone number ___________________________________________________

Email address ____________________________________________________________

Home address ____________________________________________________________

Home telephone number ___________________________________________________

Passport number ___________________ Passport expiration date ___-___-20___

Place of birth ________________________ Date of birth ___-___-19___

Health insurance company name _______________ Policy # ______________________

Please note any serious allergies or health conditions _____________________________

Previous travel experience __________________________________________________

________________________________________________________________________

Location preference: (please indicate preference by numbering, no guarantee that preference will be honored)
___ Universidade Estadual do Norte Fluminense, Campos dos Goytacazes, Rio de Janeiro http://www.uenf.br
___ Universidade Federal do Amazonas, Manaus, Amazonas http://www.fua.br

Academic Information:

Year in school _______________________ GPA _______________________________

Major(s) ____________________________ Minor(s) ____________________________

Language proficiencies ____________________________________________________

Experience with Portuguese _________________________________________________

Name of reference #1 ______________________________________________________

Department/Institution_________________ Title _______________________________

Address ____________________________ Phone ______________________________

Name of reference #2 ______________________________________________________

Department/Institution ________________ Title _______________________________

Address ____________________________ Phone ______________________________

Emergency contact information:

Name __________________________________________________________________

Address ________________________________________________________________

Telephone number __________________________ Relationship to applicant _________

Checklist:

___ completed application

___ two letter’s of recommendation requested

(sent directly to 210 Dolan, Attn: Christine Bowers,

Fairfield University, Fairfield, CT 06430)

___ transcript

___ 1 page personal statement,

indicating why the applicant desires to study abroad in Brazil

___ signed release form

(below)
** send completed packet of information (including all items on above checklist) to Christine Bowers, 210 Dolan House

Agreement and Release:

I, the undersigned, an applicant for the Study Abroad in Brazil Program (hereafter referred to as the Program), do waive and release all claims against Fairfield University and its agents, any tour organization or arranger employed or utilized by the University, host schools or institutes, for any injury, loss, damage, accident, delay or expense resulting from the use of any vehicle, strikes, war, weather, sickness, quarantine, government restrictions or regulation, or arising from any act or omission of any airline, railroad, bus company, taxi service, hotel, restaurant, school or other firm, agency, company or individual. I also release Fairfield University and its agents and agree to indemnify them with regard to any financial obligations that I many personally incur or any damage or injury to the person or property of others that I may cause, while participating in the Program.

I hereby grant Fairfield University and its agents full authority to take whatever actions they may consider to be warranted under the circumstances regarding my health and safety, and I fully release each of them from any liability for such decision or actions as may be taken in connection therewith. I authorize Fairfield University and its agents, at their discretion, to place me, at my own (or my parents’) expense, and without my further consent, in a hospital within or outside the United States for medical services and treatment, or, if no hospital is readily available, to place me in the hands of a local medical doctor for treatment. If deemed necessary or desirable, I authorize them to transport me back to the United States by commercial airline or otherwise at my own (or my parents’) expense for medical treatment. In the event that Fairfield University or its agents advance or loan any monies to me, or incur special expenses on my behalf while I am abroad, I (and my parents) agree to make immediate repayment upon my return.

I will comply with Fairfield University rules, standards and instructions for student behavior. I hereby waive and release all claims against the University and its agents arising at a time when I am under direct supervision of its agents or arising out of my failure to remain under such supervision or comply with such rules, standards and instruction; and I agree to indemnify the University and its agents against any consequences thereof. I agree that the University shall have the right to enforce appropriate standards of conduct and that it may at any time terminate my participation in the Program for failure to maintain these standards, or for any actions or conduct considered to be incompatible with the interest, harmony, comfort and welfare of other students. If my participation is terminated, I consent to being sent home at my own (or my parents’) expense with no refund of fees.

I understand that Fairfield University is not responsible for any injury or loss whatever suffered by me during periods of independent travel (which I understand are unsupervised) or during any absence from the Program supervised activities. I will also accept in good faith the instructions and suggestions of the Program director(s) in all matters relating to the Program or the personal conduct of Program participants.

I understand that Fairfield University reserves the right to make cancellations, changes or substitutions in cases of emergency or changed conditions. I also understand that if I leave the Program voluntarily for any reason, there will be no refund of tuition fees already paid.

All references in the Agreement and Release to Fairfield University and "its agents" shall include the University and all of its Program directors, staff members, campus directors and affiliated organizations. All references herein to "parents" of the applicant shall include the legal guardian or other adults responsible for the applicant.

Signature of Applicant _____________________________________________ Date _________________

I certify that I am the parent or legal guardian of the above applicant, and that I have read the foregoing Agreement and Release (including such parts as may subject me to personal financial responsibility) and hereby relinquish any claims that I might have against Fairfield University or its agents (as set forth above), both on my behalf and in my capacity as legal representative of the applicant.

Signature of Parent or Guardian ______________________________________ Date _________________

(required of students who are not yet age 21)