APPLICATION FOR

GEORGIA SOUTHERN UNIVERSITY’S

STUDY ABROAD PROGRAM

A LITERARY TOUR OF ENGLAND

Summer 2005

Please complete this form and send it along with a $100 registration fee to Professor John Humma,

Department of Literature and Philosophy, P.O. Box 8023, Georgia Southern University, Statesboro,

G.A. 30460-8023. Application deadline is March 15, 2005.

Name (first, middle, last)_________________________________________________________

Social Security Number ___-__-____ E-mail address_______________________________

Date of Birth________ ____Citizenship______________________________Gender_______

Present Mailing Address_________________________________________________________

City______________________________________State_____________Zip Code___________

Present Telephone Number (with area code)__________________________________________

Emergency Contact __________________________________Phone Number_______________

Permanent Mailing Address_______________________________________________________

City_______________________________________State_____________Zip Code___________

Current class standing (circle one) Freshman, Sophomore, Junior, Senior, Graduate

Major_________________________Minor___________________Expected Graduation_______

Other institutions attended (please include dates, major and degree earned (if any):

Health problems or physical disabilities:

E. Authorization and Waiver of Liability: Read and sign the following statement

I acknowledge that participation in a study abroad program involves some risk of injury, illness, or loss of personal property. I agree to release and forever discharge Georgia Southern University, the Board of Regents, and the University System of Georgia, its members individually, and its officers, agents, and employees, from any and all claims, demands, rights, and causes of action of whatever kind or nature, arising from and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries, including death, damages to property and the consequences thereof, resulting from my participation in the 2005 Summer Studies.

I certify that, to the best of my knowledge, I am in good health and physically capable of undertaking an intensive program of foreign study; any medical or health-related problems have been explicitly described in this application. I further agree that I shall be subject to the supervision and authority of the faculty in charge and to standards of conduct stipulated by the faculty in charge. I further acknowledge that the supervising faculty or program director has sole authority to make decisions regarding the continued participation of any individual in the program whose conduct may necessitate disciplinary action. I further authorize the supervising faculty or program director to obtain and provide medical treatment and/or services that I may require during the study abroad program. Finally, I am aware that the deadline for submission of this application is March 15, 2005, and I agree to abide by the deadlines for fee payment as follows: March 15, 2005, $100 application fee plus first payment of $1,450; April 29, 2005, final payment of $1450. I further acknowledge and accept the schedule for refunds, should I withdraw from the program, and accept the penalties associated with late withdrawal, as follows:

Withdrawal before April 1: All but $50 will be refunded.

Withdrawal between April 2 and May 3: All but $150 will be refunded.

Withdrawal between May 4 and May 30: All but $1,200 will be refunded.

Withdrawal after May 30: No money will be refunded.

Note: All withdrawals must be made in writing to the Center for International Studies at Georgia Southern University in order for refunds to be processed.

I understand that submitting an application for this study abroad program does not guarantee acceptance into the program; that candidates must meet program requirements and be approved by their campus faculty representative; and that participation is subject to availability and is on a first come, first served basis.

___________________________________________________________ ________________

Signature of Applicant Date

Signature of parent/guardian for applicants under 18 years of age

In case of injuries, I hereby authorize and give consent to the program leaders to obtain and provide medical treatment and services for my son or daughter as deemed

necessary.

___________________________________________________________ ________________

Signature of Applicant Date

F. Recommendations and Official Signatures

This applicant is recommended for admission to the 2005 Literary Tour of England study abroad program.

___________________________________________________________ ________________

Signature of Study Abroad Coordinator or Program Director Date

NOTE: APPLICATION FORM MUST BE ACCOMPANIED BY $100 APPLICATION FEE