Travel Study Registration

Have you ever attended or applied to UCLA before? Yes No

If yes, what is your UCLA ID?

Name and Address

Mailing address, telephone, and email address will be released unless you check the appropriate boxes. If you do not check the boxes, please note that your information may be released. Once your registration is processed, you may update these privacy options using URSA OnLine.

Last Name: First Name:

Middle Name: Suffix:

Other Names on File at UCLA:

Last Name: First Name:

Middle Name: Suffix:

Present Mailing Address: Release Do Not Release

Street Address 1:

Street Address 2:

City: State: Zip:

Present Telephone Number (area code first): Release Do Not Release

Email Address (required): Release Do Not Release
(Please use an email address that you check frequently.)

Permanent Address: Release Do Not Release

Street Address1:

Street Address2:

City: State: Zip:

Permanent Telephone Number (area code first): Release Do Not Release

Personal Information

Social Security Number (numbers only):

Citizenship:

Ethnicity:

Do you have a passport? Yes No

If yes, what is your passport number (if available):

Are you a permanent resident (non US citizens only)? Yes No

Birth Date (Month/Day/Year): / / -- mm/dd/yyyy

Place of birth:

Gender: Male Female

Roommate Request (Same Gender Only):

Is it okay to release information about your program itinerary (i.e. phone number of where you can be reached during your program) to your parents or guardians? Yes No

If yes, please list the full names of your parents or guardians.

Academic Background

Do you have a Baccalaureate degree (B.A./B.S.)? Yes No

Graduating college senior this summer? Yes No

Where registered Spring 2010?

UCB
UCD
UCI
UCLA
UCM
UCR
UCSB
UCSC
UCSD

UCSF
UCLA Extension
Other 4-year College/Univ. in U.S.
Attend 2-year college
Attend High School
High School Grad
Outside of U.S.
None of these

If you plan to enroll in college in Fall 2010, what will your class level be?
Freshman Sophomore Junior Senior Graduate Student

Will you be a UC student in Fall 2010?

No Yes -- which campus I don't know

If you attended a UC campus, please list your student ID #:

School Presently attending (if not a UC campus):

Major:

Minor:

Health and Welfare

For your safety, it is important that you disclose all health conditions you may have. All information is confidential and will only be used in the event of an emergency. The personal health information you provide here is not used to determine your eligibility for participation on your UCLA Travel Study Program. However, if you have a serious health condition, please notify the Travel Study Office immediately so we can advise you whether your condition can be reasonably accommodated abroad.

Please describe in detail any medical conditions you have:

Please list any current or recent mental health conditions (such as anxiety, bipolar disorder, clinical depression, drug or alcohol dependency, etc.) for which you have sought treatment:

Please list any medications that you take:

Please indicate any dietary restrictions you have:

Special Needs:

Smoker Nonsmoker

Travel Study Programs Application

Health Insurance - International Programs

A traveler's health insurance policy is provided by HTH Worldwide for international programs. Coverage is for the dates of the program only. Policy information will be available soon.

Health Insurance - Domestic Programs

A traveler's health insurance policy is provided by ACE for domestic programs. Coverage is for the dates of the program only.

UC Health Insurance Benefits Summary
UC Health Insurance FAQ

A Special Note about Domestic Programs

While a traveler's health insurance policy is provided for domestic programs, you may wish to provide information about your current health insurance coverage in case of emergency:

Health Insurance Provider:

Health Insurance Policy Number:

Provider Street Address:

City: State: Zip:

Insurance claims telephone number (area code first):

Emergency Release Information

Contact 1:

Name of contact person in case of emergency:

Relationship:

Home telephone (area code first):

Work telephone (area code first):

Street Address:

City:

Email Address (optional): State: Zip:

Contact 2:

Name of contact person in case of emergency:

Relationship:

Home telephone (area code first):

Work telephone (area code first):

Street Address:

City:

Email Address (optional): State: Zip:

Program and Course Selection

You may select only one Travel Study program. If you are planning to participate in more than one program this summer, please e-mail ieo@international.ucla.edu.

Select	Program Location	Required Courses	Optional Courses (no fee)	Optional Courses (additional fee)	Instructor Consent
	Asian American Studies (143D, 143C) Honolulu, Hawaii	187A, 143C		199
	Asian American Studies (143D, 143E) Honolulu, Hawaii	187A, 187C		199
	Asian Languages and Cultures Shanghai, China	CHIN 103, HIST 170B
	East Asian Studies Beijing, China	191A, 191B
	English Shakespeare Stratford and London, UK	142A,142B 142A,142C 142B,142C		199
	Environmental Science Thailand	131SL, 188			Y
	French (Business) Paris, France	109, 110	199
	French (Advanced) Paris, France	100, 107, 130
	French (Intermediate) Paris, France	4, 5	14
	German Studies Vienna, Munich and Berlin Please select 2-3 courses total	100C 61A 100C,61A 141	1 2 3 4 6	199
	Global Studies Brazil	110A, 110B
	Global Studies Paris, France	110A,110B		199
	Global Studies New York City	110A,110B
	Global Studies Shanghai, China	110A,110B
	History Paris, France	119D, 191B		HIST199 (1) HIST 199 (2) SPAN199	Y
	History Greece	112B, 112D		199
	History Rome, Italy	112C, 112E		HIST 199 CLASSICS 199
	History Spain and Morocco	108B, 191F		199
	International Business Law Barcelona and Madrid, Spain	109, 127C		199
	Italian (Elementary) Florence, Italy	1,8A,8B,42A		199A
	Italian (Intermediate) Florence, Italy	4,8B,8C,42A		199A
	Jewish Studies Israel	NE 50B, Hist 182D or NE 50B, JS 182D
	Music Venice, Vienna, Salzburg and Paris	174, 175
	Political Science (Section 1) London, Brussels, Amsterdam and Paris	153A, 127A		199
	Political Science (Section 2) London, Brussels, Amsterdam and Paris	119, 153A		199
	Portuguese (Elementary) Salvador Bahia, Brazil	102A, 102B, 191		199
	Portuguese (Intermediate) Salvador Bahia, Brazil	102B, 103, 191		199
	Portuguese (Advanced) Salvador Bahia, Brazil	103, 105, 191		199
	Sociology New York City	191N, 191R		195
	Spanish Costa Rica	191B,119A 191B,147 119C,147		199
	Spanish (Elementary) Barcelona, Madrid, and Granada,Spain	2A, 3A		199
	Spanish (Intermediate) Barcelona, Madrid, and Granada,Spain	4, 5		199
	Spanish (Advanced) Barcelona, Madrid, and Granada,Spain	105, 191		199
	Spanish (Intermediate) Merida, Mexico	4, 5		199
	Spanish (Advanced) Merida, Mexico Advanced Spanish Composition	25, 119A		199
	Spanish (Mexican Literature) Merida, Mexico Mexican Literature and Culture	144B, 144C		199
	Urban Planning Geneva, Switzerland	C260, C266, 496 (grad) CM160, CM166, 199(undergrad)

How did you hear about this program?

Catalog	Flyer EAP	Former Program Participant
Web site	Dept./Professor	Counselor
Study Abroad Fair	UC Travel Study Email	FaceBook	Other:

Have you ever studied or traveled internationally before? Yes No

If yes, how many times?

If yes, please indicate the duration of your longest international experience:

If yes, please indicate the countries you visited:

Travel Study Programs Application

Payment

In order to secure your place on the program, a $300 non-refundable deposit payment is due at this time. You may pay by credit card using our secure online credit card form at the end of this application process. Please note that your credit card will be charged immediately and that your deposit is not refundable. If you do not submit a valid credit card payment at the end of the application process, you will not hold a spot in your Travel Study Program.

If your program requires instructor consent or if you are waitlisted for a program, your payment will not be due until your application is approved by the instructor or accepted from the waitlist. You will be notified by e-mail with payment instructions.

Please note that UC prices apply to students who will complete their degree after spring 2010. UC students graduating by spring 2010 are not eligible for UC rates.

Fees are subject to change by action of the UC Regents.

Cancellation Policy

The $300 deposit is not refundable under any circumstance;
Paid program fees (minus the $300 deposit) are refundable until April 2, 2010;
No refunds are available after April 2, 2010.

Travel Study Programs Application Student Agreement

I understand that, as a student in a UCLA Travel Study Program, I must:

Be at least 18 years of age and have completed high school by June 2010.

Assume full legal and financial responsibility for my stay abroad.

Take full responsibility for program fees (even if I am a financial aid student); pay all program fees by the necessary deadlines; and read and understand the UCLA Travel Study cancellation and drop policies.

Complete the mandatory courses for a letter grade, attend scheduled classes and field trips, and fulfill all other program requirements.

Make my own transportation and passport arrangements (as necessary).

Submit a digital photo (all students) and a digital copy of the front page of my passport (international programs only) within 90 days of my application.

Understand that these programs are 1) academically rigorous and geared for mature students already familiar with college level courses and 2) physically rigorous and that my health allows me to participate fully.

Understand that my participation in my Travel Study Program is voluntary and that Travel Study Programs carry with them unanticipated and unforeseeable risks of danger to my health and safety which may not be found in study on campus, including death, bodily injury, property damage and illness, and I expressly agree to assume the risks by my voluntary participation in this non-required activity.

Be responsible for all expenses related to any personal accident, injury or illness which may occur during the time in which I am participating in the UCLA Travel Study program and be prepared to pay for all medical expenses in full at the time of treatment.

Bear financial responsibility for single room accommodations based on medical necessity as determined by the Program Director.

Grant UCLA, its faculty and administrators, full authority to act in an attempt to safeguard and preserve my health and safety during my participation in the Travel Study program, including authorizing routine or emergency medical treatment on my behalf and at my expense, and returning me to the United States at my own expense (if necessary).

Respect the laws and customs of the host country, the UCLA Student Conduct Code and all other reasonable standards of conduct related to my Travel Study Program promulgated by UCLA faculty and administrators.

Accept termination of participation in the Travel Study program with no refund of fees and take responsibility for transportation costs to my home if my conduct is determined to be detrimental to the best interests of the program. Such a decision is to be at the sole discretion of the faculty Program Director, with appropriate consultation with the administration of UCLA Summer Sessions.

Forfeit any refund if I decide for any reason to terminate my participation in the program after it has begun.