USA Study Abroad Application

Fields marked with an * are required

Select Semester *

Select Trip Dates *

Other

If other, please specify

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Personal Info

First Name *

Last Name *

Full Address *

Gender *

Female
Male

Phone *

Email *

Emergency Contact

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

Alternate Phone

Passport Info

Passport Number

Issuance Date

Expiration Date

Date of Birth *

Place of Birth *

Country of Citizenship *

Education

Current School *

Grade Level *

Gymnasium
Realschule
Other

School Mailing Address

Academic Studies

English Language Previous Experience *

Primary Language and Other Languages Spoken

Medical History

List any medical conditions for which you are currently under treatment (N/A for none) *

Have you ever been treated or are currently being treated for any physical, psychological, or emotional problems of which the Reading Institute should be informed? If yes, explain *

List any medications you are currently taking (N/A for none) *

List any allergies and the reactions (N/A for none) *

Health Insurance Info

Name of Insurance

Policy Number

Group Number

Agreement, Acknowledgement and Consent

I agree *

I acknowledge, understand, and appreciate that despite the most careful planning and supervision, participation in this program involves risks to which I may be exposed, including the risk of serious physical injury, disability, and death, as well as economic A property loss. The dangers, hazards, and risks may arise from my own actions, inactions, or negligence as well as from the actions, inactions or negligence of others, or the condition of the premises. I voluntarily accept and assume all risks and responsibility for my health, safety, and property while participating in this program.

I agree *

I hereby for myself and on behalf of my heirs, family members, assigns, executors, personal representatives, and next of kin, agree to release, indemnify and hold harmless, the Reading Institute of Higher Education, hereafter referred to as Reading Institute, its respective officers, agents, volunteers, and employees from any liabilities, damages, expenses, causes of action, claims, or demands of any nature whatsoever, including any claims of negligence, on account of personal injury, property damage, death, or accident of any kind, related to my participation in this program.

I agree *

In the event of an accident or serious illness, I hereby authorize representatives of Reading Institute to obtain medical treatment for me, on my behalf. I hereby hold harmless and agree to indemnify the Reading Institute.

I agree *

I understand that the Reading Institute does not provide any accident or medical insurance, and I am expected to provide my own health insurance. I hereby agree that I am financially responsible for all such expenses. I will be responsible for the supply and use of my prescribed medications while in the United States of America.

I agree *

I declare that I am in good academic standing with my current institution of education and meet its eligibility requirements to study abroad.

I agree *

I declare that I am in good disciplinary standing with my current institution of education and am not under disciplinary probation as a result of any Code of Conduct violations. Furthermore, I understand that while traveling and while in the United States I am subject to and agree to abide by the Student Conduct Code of my institution of education, laws of the United States, laws of the Commonwealth of Pennsylvania, and laws of any other areas I am visiting; and that in the event of violation of these, or behavior which is considered to be detrimental to myself or other participants, Reading Institute shall have the right to dismiss me as a participant of this program while retaining all payments.

I agree *

I understand that withdrawal from the Reading Institute must be submitted either by a signed letter or email. The student may be eligible for a full refund if cancellation is received within one week after the deadline for registration. Any cancellation after one week following the deadline will be processed at 50% refund. Refund amounts for cancellation due to exceptional circumstances will be considered by Reading Institute on an individual basis.

I agree *

I declare that the information given in this Application is complete, true, and correct. I understand that if any of the information on this form is found to be false or omitted, it will result in immediate dismissal from the program while retaining all payments. I agree that if any of the information on this form changes, I will provide updated information to the Reading Institute within 7 days.

I agree *

I agree and consent that by printing my name below I, therefore am providing my Electronic Signature to this Application, Acknowledgement and Consent Form. I understand that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically.

Esignature - Print Full Name *

Date *

Parental Consent

Parent/ Legal Guardian Full Name *

Parent/ Legal Guardian Full Name

Parent/ Legal Guardian Address: (if different from student)

150 of 150 Character(s) left

We/I agree *

We/I, the undersigned, are the parent(s) or legal guardian(s) of the child/youth named in this application. As parent(s) or legal guardian(s), we/I affirm that we/I have been informed of all the activities in this study abroad program.

We/I agree *

We/I, the parent(s)/ legal guardian(s), hereby give permission for my child, child/youth named in this application, to participate in the Reading Institute’s Study Abroad Program, and to travel to Reading, Pennsylvania, USA from Dresden, Germany.

We/I agree *

We/I have read and are in agreement with the declarations and all statements in the Agreement, Acknowledgement and Consent portion of this form. We/I agree and consent that by printing our names below we/I, therefore are providing our Electronic Signatures to this Application, Acknowledgement and Consent Form. We/I understand that all electronic signatures are the legal equivalent of manual/handwritten signatures and we/I consent to be legally bound to this agreement. We/I further agree our signatures on this document are as valid as if we/I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should we elect to have signed electronically.

*Both signatures are required by parents or legal guardians. In case of a single parent or legal guardian, one signature is sufficient.