Irish Studies Student Application

Personal Information

First Name

Middle Name

Last Name

Birthdate

Sex

Country of Citizenship

What is your hometown?

Country

City

Region

Postal Code

*hidden* Address Type

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Social Security Number

At what university are you currently enrolled?

Major

Cumulative GPA

Classification

Which term will you be attending the Irish Studies Program?

Mobile Phone

Email Address

If you do not have a JBU Network Account, one will be created for you upon submission of this form. By submitting your password recovery email address on this form, you authorize us to use it to help you recover your account password if you ever forget it. Within 24 hours after submitting this form, you will receive an email message with instructions on setting your initial password and using your new account.

Password Recovery Email Address

JBU's International Office will need to contact your school's study abroad office. Please provide your school's study abroad contact's name and email.

Study Abroad Contact Name

Study Abroad Contact Email

Voluntary Information

Colleges and universities are asked by many groups, including the federal government, accrediting associations, college guides, and newspapers, to describe the ethnic/racial backgrounds of their students and employees. In order to respond to these requests, we ask you to answer the following question. View Definitions

Definitions

American Indian or Alaska Native: For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

Asian: For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.

Black or African American: For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.

Hispanic or Latino: For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.

Middle Eastern or North African: For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.

Native Hawaiian or Other Pacific Islander: For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.

White: For example, English, German, Irish, Italian, Polish, Scottish, etc.

Please check one or more of the following groups in which you consider yourself to be a member:

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Authorization for Release of Medical Information:

I authorize JBU’s Counseling Center and University Nurse to indicate any reservations for international team involvement based on my personal medical and/or health records. This information may be released to the International Programs Office and the Irish Studies team leader(s) and members. Only pertinent information will be shared on my behalf to determine if there is presently any physical or mental health condition(s) that might compromise my safe participation in the program. This authorization may be revoked at any time, but that revocation will not affect any information already released.

Signature

Date

Authorization for Release of Conduct Record:

I authorize my Home Institution's Student Development Office, or equivalent, to indicate any reservations for international team involvement based upon my university conduct record.

Signature

Date

Irish Studies Community Covenant:

I understand and commit to uphold the Irish Studies’ Community Covenant as a member of this international education team. Should I break the covenant, I may be sent home immediately at my own expense if the on-site director deems it necessary for the best interests of myself and the team. Moreover, I will be subject to a disciplinary process carried out by John Brown University.

Signature

Date

Irish Studies Allocation of Funds and Travel Policy:

I acknowledge that funds I pay for the Irish Studies Program will be applied toward team fees and expenses. I agree to release any claim to such funds needed and paid as non-refundable deposits for travel and lodging should I withdraw from the Irish Studies Program or should the trip be canceled due to either a State Department warning or a situation which the university deems to be a safety risk. Any funds recovered by JBU and not applied to incurred expenses will be returned to me. I agree to follow the group travel itinerary and will not make separate or divergent arrangements without written approval from the team director.

Signature

Date

Transcript Request:

I authorize the release of my academic records maintained by John Brown University to the college listed below to document my Study Abroad courses and grades at the end of my semester of study. I understand that I have the right to rescind this authorization at any time by notifying the Office of the Registrar at John Brown University in writing of my decision. I understand that such revocation will not affect any disclosures previously made before receipt of any such written revocation.

Signature

Date

Home Institution

Irish Studies Registration Information

Please select at least 12 credit hours of coursework. All courses are three credit hours. Honors credits are available upon request. Students attending in the spring are required to take the Peace & Conflict Reconciliation course.

Please select at least 12 credit hours of coursework. All courses are three credit hours. Honors credits are available upon request.

Please select at least 9 credit hours of coursework. All courses are three credit hours. Honors credits are available upon request.

Irish Art and Culture

Evangelical Theology

Christian Formation

Integrated Humanities II

Intercultural Communication

Peace and Conflict Reconciliation (REQUIRED)

Global Business

Irish Literature

CS Lewis (REQUIRED)

Irish Studies Acknowledgements and Waiver of Liability

DISCLAIMER

JOHN BROWN UNIVERSITY (JBU) and JOHN BROWN UNIVERSITY NORTHERN IRELAND (JBUNI ARE NOT RESPONSIBLE FOR ANY INJURY (OR LOSS OF PROPERTY) TO ANY PERSON SUFFERED WHILE PARTICIPATING IN THE IRISH STUDIES PROGRAM, OR IN ANY OTHER WAY INVOLVED WITH THE IRISH STUDIES PROGRAM FOR ANY REASON WHATSOEVER. THIS RELEASE INCLUDES ANY ORDINARY NEGLIGENCE ON THE PART OF JBU, JBUNI, STUDENT’S HOME INSTITUTION, AND/OR AGENTS, EMPLOYEES, VOLUNTEERS, OFFICERS, AND BOARD OF TRUSTEE MEMBERS OF SAID INSTITUTIONS.

Waiver and Release of Liability

I understand that although the Irish Studies Program will make reasonable efforts to assure my safety while participating in the Program, there are unavoidable risks in travel abroad and/or in other parts of the United States. Further, I affirm that I am aware that international travel involves certain risks, including, but not limited to, death, personal injury, and property damage resulting from travel accidents, sickness, the uncontrollable nature of the encounters with other persons that may occur, and situations in the country(s) being visited, such as, but not limited to, civil unrest, epidemics, pandemics and unstable governments. In addition, I understand that participation in international travel may involve sites that may be remote from available medical assistance. I agree that the program sponsors cannot guarantee my total safety since some risks are beyond their control. I agree to follow all instructions and guidelines given by them, and to act in a safe and responsible manner toward all participants and others with whom I come in contact. I am voluntarily participating in this activity with knowledge of the danger involved and hereby agree to accept any and all inherent risks of property damage, personal injury, or death.

In consideration of my participation, I hereby release and covenant not to sue JBU, JBUNI, my home institution, said institutions’ Board of Trustees, employees, volunteers, officers, and/or agents, from any and all present and future claims resulting from ordinary negligence for property damage, personal injury, or wrongful death arising as a result of my participating in study abroad activities or any activities incidental thereto, wherever, whenever, or however the same may occur. I, and on behalf of my estate, hereby voluntarily waive any and all claims resulting from ordinary negligence, both present and future, that may be made by me, my family, estate, heirs, or assigns. I further agree to indemnify and hold harmless my home institution, JBU, JBUNI and others listed for any and all claims and legal fees arising as a result of my participation in the Irish Studies Program activities or any activities incidental thereto, wherever, whenever, or however the same may occur.

Health Insurance and Health Expenses

I have or will secure health insurance to provide adequate coverage for any injuries or illnesses that I may sustain or experience while participating in the Irish Studies Program. I am or will become familiar with my insurer’s conditions and procedures for making a claim. By my signature below I certify that my health care coverage will adequately cover me while traveling both inside and outside of the United States, especially in the United Kingdom, Republic of Ireland, greater European region, and other regions where I may travel arrangements. I hereby release my home institution, JBU, JBUNI, and its employees and agents from any responsibility or liability for expenses incurred by me for injuries or illnesses (including death).

Other Program Acknowledgements

I understand that although my home institution, JBU, and JBUNI will attempt to maintain the Irish Studies Program as described in its publications and brochures, it reserves the right, for programmatic, political, or other reasons, to change the Irish Studies Program, including itinerary, travel arrangements, or accommodations, at any time and for any reason, with or without notice.

I understand that this is a supervised program and I agree to uphold individual and group standards set out by my home institution, JBU and JBUNI. I understand that the Irish Studies Program Director has the right to dismiss me from the Program at any time should my actions, overt or covert, in the sole discretion of the Irish Studies Program Director, be determined to impede or obstruct the progress of the study abroad program, or violate the individual and group standards set forth. The costs associated with my dismissal will be my responsibility.

I understand that this waiver is intended to be as broad and inclusive as permitted by the laws of the state of Arkansas and my home state and agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for any legal proceedings shall be in the state of Arkansas.

This agreement represents my complete understanding with my home institution, JBU, JBUNI concerning my home institution, JBU, and JBUNI’s responsibility and liability for my participation in the Program. It supersedes any previous or contemporaneous understandings I may have had with my home institution, JBU, and/or JBUNI on this subject, whether written or oral, and cannot be changed or amended in any way without written concurrence by me and by an authorized agent of my home institution, JBU, and JBUNI..

I have read this form and fully understand that by signing this form, I am giving up legal rights and/or remedies which may be available to me for the ordinary negligence of JBU, JBUNI, my home institution or any of the parties listed above. I represent that my agreement to the provisions herein is wholly voluntary, and I further understand that, prior to signing this agreement, I have the right to consult with an advisor, counselor, or attorney of my choice. I affirm that I am at least eighteen years old.

Signature

Date

Irish Studies Health Record and Personal Authorization

Health Insurance Company

Health Insurance Phone Number

Please share any important medical history (i.e. diabetes, epilepsy, anemia)

Do you have a medical disability?

If yes, please explain:

Are you currently under a physician’s care?

If yes, please explain:

Have you been under medical, psychiatric, or a counselor's care in the past year? If yes, please explain.

May we contact the person(s) who provided your care? If yes, please list their contact information. (Name & phone number)

If you have had major surgery, please share what type.

Please list any severe allergies to medication, food, plants, insect bites, or other items.

Please list any prescription medications you take on a frequent or regular basis.

Do you have any existing health conditions needing medical attention or monitoring such as special diets, medication levels, etc.?

Authorization and Permission for Treatment: Consent is hereby given for treatment by licensed medical personnel, including necessary emergency procedures such as non-elective surgery and hospitalization. If I am incapacitated or otherwise unable to give release for medical treatment, consent is hereby given to a university representative to authorize needed care on my behalf. No guarantee has been made to me as to the results to be obtained by treatment given. It is understood that the university representative will contact the designated, authorized person(s) in the case of an emergency or serious illness. I understand that I am responsible for charges incurred due to illness, injury, or accident (whether authorized by me or by the university’s representative on my behalf).

Signature

Date

1. Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Mobile Phone

2. Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Mobile Phone

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