On Campus Plus University Abroad Program Application Form 2015 – 2017 All fields must be completed. I am applying for a place at: (name of host college/university)
Student details Family name: First/given names: Date of birth: m m / d d / y y
Male
Country of birth:
Current citizenship:
Female
Own language: Home address:
Country: Mailing address (if different from home address):
Country: Telephone:
Mobile telephone:
Fax:
Email:
Passport number:
Passport expiry date: m m / y y
Parent/guardian details Family name: First/given names: Relationship to student:
Male
Female
Home address:
Country: Home telephone:
Business telephone:
Mobile telephone:
Fax:
Email:
Personal and medical information Please provide details of any medical conditions which require notification to Kings and/or require any prescribed medication.
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Personal and medical information continued If you are not a US citizen, or lawful permanent resident, and you already have a visa, please indicate the type.
Do you have a criminal record? (except traffic violation). If yes, please provide details.
Student insurance See Terms & Conditions for details of insurance requirements. Once you commence the University Abroad Program, you will need to take out separate student insurance as required by the host college/university. For students following a Kings Undergraduate Preparation Program, the cost of Kings student insurance will be automatically added to your invoice, unless you provide proof of alternative cover once your application has been accepted. Full details will be provided as part of your offer documents.
Intended start date August 2015
/ January 2016
/ August 2016
/ January 2017
Intended duration One semester
/ Two semesters
Please indicate your preferred subject stream, if known (please refer to the specific brochure of your chosen location for details):
Current level of English Please indicate your current level of English. (Please include a transcript of your formal test results with your application). If you have an official TOEFL score, please send it directly to Kings Education using the ETS website via code 6891 Date
Name of Examination or Certificate
Grade or score
Accommodation requirements Students will be accommodated in a twin room on campus. Check in date:
m m / d d / y y
Check out date:
m m / d d / y y
Please note: Please note, depending on your chosen location, either dormitories or the entire campus may be non-smoking. Do you have any special requirements? (eg. allergies, special diet)
Airport transfer Please tick this box if you require an airport transfer — we will contact you for further details.
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Previous education Please provide details of your current or most recent school or college. Please include with your application certified copies of all academic transcripts or reports (translated into English) for all high schools or colleges you have attended. Name and address of school (including country)
Type of institution
From
To
GPA (if known): If not currently enrolled, or you have any long gap/s between study periods, please indicate what you did while you were not a full-time student.
Have you ever been dismissed from a college or university? If yes, please provide details.
Personal interests Please include details about relevant personal interests in the boxes below. Please use a separate sheet if necessary. Academic Interests
Athletics
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Extracurricular Activities
Awards and Recognition
Future educational plans Please say what you hope to do after your University Abroad Program.
Family Educational Rights and Privacy Act (FERPA) Waiver: Authorization for release of information For the purpose of allowing others to assist me with my education, Kings Education and my chosen host college/university may release information in my student record as necessary to facilitate evaluation, transfer, credit or management of my application, enrollment and continued progress at Kings Education or my chosen host college/university. This authorization specifically permits the sharing of information in both directions between Kings Education and my chosen host college, and from those parties to any person named below, who is directly responsible for my recruitment or continued participation in the University Abroad Program at my chosen host college/university. I understand that I have the right to revoke this authorization at any time. Sponsor name
Grant authorization
Withdraw authorization
My Agency (Representative Name)
Grant authorization
Withdraw authorization
My Parent(s) or other relative
Grant authorization
Withdraw authorization
Other: (Please print)
Grant authorization
Withdraw authorization
Signed declaration
Signature of student:
Signature of student’s parent/guardian (for students under 18):
Date: m m / d d / y y
All students under 18 years of age are required to have this application signed by a parent and/or sponsor. An additional release form will be required.
Kings Education and host colleges/universities do not discriminate on the basis of race, color, ethnicity, national origin, religion, creed, sex, age, marital status, parental status, physical disability, learning disability, political affiliation, veteran status, or sexual orientation.
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I certify that all information submitted by me in this application is my own work, and is complete and accurate to the best of my knowledge. I understand that any misrepresentation or omission of facts in my application justifies a denial or cancellation of admission. I hereby apply for the University Abroad Program, and accept the Terms & Conditions outlined in this application pack, and online at kingseducation.com