Global Health Issues and Systems in Armenia

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in Armenia

Application

Dear Student!

Thank you for your interest in the Global Health Issues and Systems study abroad program. Please complete and return this application, program deposit, an unofficial USC transcript, and Deposit and Withdrawal Information Form by Friday, January 31, 2014 to:

Attn. Dr. Vahé Heboyan 915 Greene Street, Room 358 Discovery Building

University of South Carolina Columbia, SC 29208

Tel.: (706) 461 0158; eMail: VHeboyan@sc.edu

Make sure the following items are included with this application:

All pages of the completed and signed application (including this one).

All pages of completed and signed Global Classroom Program Deposit and Withdrawal Information Form (pp. 5-6 of this document).

An unofficial USC transcript.

Application deposit of $300.00. For the refund policy of this and remaining program fee, please see the Deposit and Withdrawal Information Form (pp. 5-6).

Only complete applications will be considered.

I understand that submitting an application for a study abroad program does not guarantee acceptance into the program. Candidates must meet program requirements and be approved by the program's faculty coordinator. Participation is also subject to availability; some programs fill up early. I understand that I will also need to complete a Global Partner Program Application with the USC Study Abroad Office by March 1, 2014.

I further understand that the program may be cancelled due to low enrollment or other factors and I understand that I will be informed of such a decision no later than 6 (six) weeks before planned departure date or as soon as possible after any adverse circumstances that cause the program to be cancelled.

Student Name

Signature Date

For Study Abroad Program Use Only:

Date Received Application Fee Received ____

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Global Health Issues and Systems | Maymester 2014 | Armenia

Personal and Academic Information

1. First Name ____________________________________ Middle Initial ________

2. Last Name ____________________________________

3. Preferred Name ____________________________________

4. Birth Date ____ ____ ________

month day year

5.

Sex

Male Female

6.

VIP ID

This is your 8 digit VIP ID. Do not use your Social Security Number or Email Username.

7.

USC ID Number

Your USC ID is made up of 1 letter followed by 8 numbers. If you do not know your USC ID: Go to https://my.sc.edu, click on "View my IDs and manage my passwords"; under the Personal section, and log in. The page entitled "Your USC Identifiers" will list your VIP ID, Network Username, and USC ID.

8.

Last 4 Digits of Social Security

9. Citizenship ___________________________________

10. eMail address ___________________________________

11.

Primary Phone

12.

Cell Phone

13. Local address _____________________________________________________________

14.

Are you a South Carolina Resident?

Yes

No 15. College ___________________________________

16. Major ___________________________________

17. Minor ___________________________________

18. Class standing

Freshman Sophomore Junior Senior Graduate

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Judicial Information

20. Do you have any previous or current sanctions with the USC Judicial Office, please list your charges, findings, and sanctions (along with the date of the incident and your hearing) below. Depending on the severity of the offense, students may not be eligible to participate in study abroad, and this is determined on a case by case basis.

Yes No If yes, please explain

21. Have you been convicted of a crime other than a minor traffic offense, or are any criminal charges now pending against you? Yes No

If yes, please explain

Convictions shall include: A finding of guilty by a judge or jury, a plea of guilty, or a plea of nolo contendere,

irrespective of the pendency or availability of any appeal or application for collateral relief. If “Yes”, explain fully, specifying the nature of the offense(s), the date(s) it/they occurred, the name and location of the court(s) and sentence(s) imposed. Please submit court documentation if appropriate.

Course Selections

By checking this box, I acknowledge that as a participant of this study abroad program I am required to register for both of the following courses and pay 6 credits of in-state tuition directly to USC for these courses:

HSPM 491-001: World Health Systems

HSPM 491-002: Armenia’s Health System in Transition

Essay

In the box below, please write a short essay expressing your reasons for joining this study abroad program. You may write about the host country's culture that interests you, how the program will be useful to you and how it may support personal, academic, and future career goals.

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Global Health Issues and Systems | Maymester 2014 | Armenia

References

Please provide names and contacts of 2 (two) individuals who can serve as academic references.

Name Relationship/Role Email Phone number

Application Agreement

I have read and understand the above provisions and agree to be bound thereby.

I further acknowledge that the information provided on this application is true and accurate to the best of my knowledge. I fully understand that providing false information during the application process may be grounds for rejecting my application or grounds for dismissal from the study abroad program.

Student Signature Date

Applicants who are accepted to participate in a USC study abroad program are required by the University of South Carolina to complete and sign a student agreement and waiver which stipulates the terms and conditions of the program, student conduct regulations and a waiver of liability.

Questionnaire

How did you first hear about this program?

Poster - where?

Flyer or brochure - obtained where?

Office of International Programs

Campus presentation - location/presenter

Program’s website / Facebook page

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Deposit and Withdrawal Information Form

Program Information

Location of Study Abroad Program (City, Country): YEREVAN, Rep. of ARMENIA Program Leader: Dr. Vahé Heboyan

Email: VHeboyan@sc.edu

Program Dates: May 13 - June 2, 2014

Number of USC Credits: 6 (six)

Program Fee: $ 1,920

Phone: (706) 461 0258 cell

Office: 915 Greene Street, Room 508 (Discovery Building)

USC Course Number: HSPM 491-001 & 491-002

Number of Transfer Credits: 6 (six)

Non-Refundable Deposit: $ 300.00

Program Fee Includes  Lodging

 Meals (3 times a day)

 Visa to enter Rep. of Armenia

 In-country transportation (program related)  Armenian language instruction

 Program related and cultural field trips, excursions and entrance fees  International emergency health insurance

 Printing and copying.

 Internet access at the host university

Program Fee Does Not Include

USC tuition and fees, airfare, personal expenses (e.g., souvenirs, snacks, phone calls, etc.).

Payment Information

For the program listed above, a non-refundable deposit in the sum of $ 300.00 is due to the program leader listed above with application. All deposits and payments must be made by check or money order payable to the University of South Carolina. Please write on the check or money order the program’s course number(s). You will be provided a receipt for each payment at the time the payment is made. You are advised to keep a copy of these receipts as proof of payment.

Additional payments will be due as follows:

Amount $ 810.00 $ 810.00 Due Date February 28, 2014 March 31, 2014

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Global Classroom Program

Deposit and Withdrawal Information Form

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Withdrawal Policy

I understand that if this program is cancelled by the University prior to departure I will be refunded the full amount of the payments I have made. However, if the University is forced to cancel a program due to safety and health concerns, acts of nature, acts of terrorism, or circumstances beyond its control, I will be refunded the full amount of recoverable costs. I also understand that if the program is delayed due to acts of nature, acts of terrorism, or circumstances beyond its control, I will be responsible for any additional costs that I may incur. If I choose to withdraw from this program for any reason, or to not register for the course(s) associated with this program, I understand that I will receive a refund of the program fee according to the refund schedule detailed below:

In addition to the $300 non-refundable deposit, the following specified costs are also non-refundable: 46-59 days prior to departure: 50% of program fee; 15-45 days prior to departure: recoverable costs only (possible forfeiture of entire program cost). Cancellations received less than 15 days from departure will receive no refund. Cancellations must be submitted in writing to the Dr. Vahé Heboyan; the date such notification is received by Dr. Heboyan is the official cancellation date. Trip cancellation insurance is strongly recommended. The $300 deposit is only refunded if student is not accepted into the program.

By signing below, I verify that I understand the above payment and withdrawal policies and agree to adhere to them.

___________________________________ _______________________

Student Signature Date

___________________________________ Student Printed Name

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