Humboldt State University

Language and Culture Program in Halle, Germany

A P P L I C A T I O N

All blanks must be completed!

Today's Date:

I. STUDENT INFORMATION:

Name:		Gender:	Gender Male Female
Student ID #		Date of Birth:	Month 1 2 3 4 5 6 7 8 9 10 11 12 / Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 < 1930

Your current address:
Street:
City:	State: Zip:
Telephone:
Current Email:

Name and Address of Parent, Guardian or Relative:
Name:
Relationship:
Your parent's or guardian's address:
Street:
City:	State: Zip:
Telephone:
Current Email:

II. ACADEMIC INFORMATION

Major:	Advisor/s:
Minor:	Grade Point Average:
Class Standing Freshman Sophomore Junior Senior Graduate Other, Explain:
College German Language Level (List courses taken):
Are you receiving Financial Aid? No Yes List names of financial aid sources:

III. STUDENT HEALTH INFORMATION
Have you been or lived abroad? No Yes If "yes" where and for how long?
Are you covered by a Health Insurance* with repatriation coverage? No Yes If "yes", who is the carrier and what is the policy number?	Carrier: Policy #:
*Note: If not insured, you will be required to buy a standard International Student Health/Accident Insurance.
Do you have any medical situation that may have an impact during your stay abroad? No Yes If "yes", explain:
Do you have any allergies? (to animals, food, environment, other) No Yes If "yes", explain:

By signing this application I state my serious intent to participate in the Halle, Germany Study Abroad Program. In addition, if accepted in the program, I will abide all regulations of the California State University and Colleges in general and the Humboldt State University in particular related to student conduct. Also, I will abide all the host institution's regulations related to student conduct. The information provided in this application is truthful and accurate to the best of my knowledge.

Signed:

If accepted you will need to complete all legally required forms for HSU Studies Abroad Programs and hold a valid passport.

If you are not an HSU student, please send a copy of your unofficial transcripts to: Halle Program Director Dept. World Languages & Cultures Humboldt State University 1 Harpst Street Arcata, CA 95521