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Study Abroad Application Form

* denotes required field

First Name*		Family Name*
Student Number*
Current Address*
City*		Province*
Postal Code*
Current Telephone*		Cell Number

If you are selected to participate in one of these programs, do we have your permission to share your contact information (i.e., email address, name, phone number, mobile phone number) with the other students who are also participating in the same program as yourself? This is done to allow you and the other students going to the same location to coordinate your travel plans with each other, etc.

Please check one No Yes

E-mail Address*
Gender*		Date of Birth*

Emergency Contact Name*
Emergency Contact email*
Relationship to you*
Emergency Contact telephone*

Faculty*		Major*
Campus*

Host Site

1^st Choice:
2^nd Choice:
3^rd Choice:
4^th Choice:
5^th Choice:

Length of Exchange:

When are you planning on going?

Have you discussed your study abroad plans with your academic advisor?
Yes No (if not please make an appointment to see your advisor before proceeding)

Are you on student loans? Yes No

Have you participated in a study abroad program?
Yes No

Do you speak any other languages?
Yes No

Please indicate your academic reference

Reference
Name*
Email*
Department*
Phone*

Do you have any special needs or require any additional supports?
Yes No
If yes please submit a document from you’re the disability Resource Office

The U of R collects information under authority of The University of Regina Act in accordance with the Local Authority Freedom of Information & Protection of Privacy Act and the Personal Information Protection & Electronic Documents Act for purposes of enrolment, academic status, and administration of programs/services. By responding to this form, you consent the use your personal information to communicate with you about department name here.

Signature*

Date*