Apply to Study Abroad

*If you are applying for the London or South Korea study abroad program, a different application is required. Please visit the respective program page.

*If you are under the age of 18, please contact Dr. Stapleton at stapleto@mc.edu

Country of Study

Semester

Year

I. Personal Information

Name

Date of Birth

700 Number

Citizenship

Do you have a passport?

YesNo

Passport Number

School Address

City

State

Zip Code

Phone

Permanent Address

City

State

Zip Code

Phone

E-mail Address

Cell Phone

Major

Minor

Advisor

Current Standing (Freshman, Sophomore, etc.)

Name of Parent(s) and/or Guardian

May they be contacted about your participation in the program?

YesNo

In case of emergency, contact:

Name

Phone

Address

City

State

Zip Code

Alternative Emergency Contact:

Name

Phone

Address

City

State

Zip Code

II. Personal Statement/Essay

Tell us about yourself. Tell how this semester abroad will impact your academic, career, and personal goals. What are some of your strengths and weaknesses, and how do you think this study abroad semester will affect those? What do you expect to learn?

III. Medical Information/ Allergies

Insurance Carrier (company)

Insured Group (employer)

Name of Insured (name of policy)

Policy Number

Name of Physician to Contact if Needed

City

State

Phone

List any allergies, current medications, or other pertinent medical information.

IV. Travel Itinerary

Date of Departure

City of Departure

Airline

Flight Number

Do you have connecting flights?

Yes No

If so, list the airline(s) and flight number(s).

Do you plan to travel while abroad?

Yes No

If so, when and where?

Statement of intent

I hereby make application for Mississippi College in the country indicated. I agree to accept supervision and authority from the Director of the Foreign Language Program at the University of which I am studying throughout my association with the program, to be bound by all rules and regulations issued by the program, and to conduct myself as a responsible representative of my university and my country. I understand that the courses taken in the Foreign Country carry credit assigned by Mississippi College, awarded by the Program Director in this country and at Mississippi College.

Country of Study

Academic Period of Study

Name as it will appear on your passport

I state that I have read and understood all information in this intent form regarding this study abroad program.

Electronic Signature

Date

Release form

In consideration of being permitted to participate in the activity described in Item I on this page during the period of time indicated in Item II on this page, said activity being conducted by Mississippi College of Clinton, Mississippi. I/we do hereby release, waive and discharge Mississippi College, its officers, trustees, staff members, campus directors, group leaders, group employees, faculty and agents from all liability to me, my spouse, legal representatives, heirs and assigns for any and all loss or damage, and any claim or damages resulting therefrom, on account of injury to my person or property during the course of my participation.

I/we agree to indemnify Mississippi College from any loss, liability, damage or cost that may be incurred during the course of my participation.

I/we authorize Mississippi College to take whatever action warranted under the circumstances relating to my health and safety and shall not hold Mississippi College responsible for such decisions or actions.
I further authorize Mississippi College and its agents at their discretion, without obtaining any further consent, to arrange such medical services and treatment as may be deemed necessary for me at the sole risk and expense of the participant. If deemed necessary or desirable by Mississippi College, I may be returned to the United States by commercial airlines or other means at my own risk and expense for medical treatment. Participants are strongly advised to take out an insurance policy to cover such risks.

By participating in this activity, I consent to the use of my photograph, comments or photographic likeness for publicity purposes by Mississippi College. MC students shall comply with policies in the current issue of the Tomahawk.

I/we expressly agree that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of my resident state, and that if any portion thereof is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect.

This release contains the entire agreement between the parties hereto and the terms of the release are contractual and not a mere recital. Participants further state that he/she has read the foregoing release and knows the contents and signs as his own free act.

In witness whereof, I hereby execute this release at MISSISSIPPI COLLEGE, Clinton, Hinds County, Mississippi on the date stated below.

I have read and agree with the contents of this release form.

Electronic Signature

Date