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Print Form

Student Participants (Please attach photo of

International Education yourself with face
approx. 1” long; may be
Bio-Data Form for any type of picture.) International Education
1024 Campus Delivery
International Fort Collins, CO 80523-1024
Tel.(970) 491-5917
Field Experience Fax (970) 491-5501

Personal Information (Print Clearly) Academic Information

CSUID: Class Standing:  Undergraduate
 Freshman  Sophomore
Name:  Junior  Senior
First MI Last
 Masters
 Ph.D.
Date of Birth: / /
Month Day Year
Expected Graduation Date: MO YR

Marital Status: Single Married Other Major:

Gender: Male Female Minor:

Ethnicity: Mark all that apply (disclosure is voluntary and will not be used in a
discriminatory manner). CSU Program Information
American Indian or Alaska Native
White, not of Hispanic origin Sponsoring Department:
Black, African American, not of Hispanic origin Host Country:
Native Hawaiian or Other Pacific Islander Host City(ies):
I do not wish to provide this information
Dates of Program From: To:
Country of Citizenship:
International Student ID Card Information
Passport Number: *Remember to activate your card online to receive your benefits*

Date Issued: ISIC Number:

Expiration Date: _____________________ ISIC Expiration Date:

Local Home Address:

Health Considerations
Perma Please read and initial the following statement:
The stress of travel and adjusting to a new culture can exacerbate
physical or psychological conditions that may be under control at
Permanent Home Address: home. If you are currently receiving treatment, or have received
treatment in the past, it is important that you share this information
with your program advisor and that you meet with your physician or
counselor to discuss how international work and travel could affect
your medical condition. You may consult your personal physician, the
County Health Dept. travel clinic, or Hartshorn Health Center for your
Cell/Local Phone: ______________________________________ travel consultation.
Email: ________________________________________________
I understand that I am responsible for consulting my physician and
Important! You are responsible for notifying International Education in getting all necessary immunizations and staying on medications
writing within 10-days of any change in address, phone or email recommended for my travel abroad.
(intled@colostate.edu). Initials:
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Releases: Please Complete and Sign Emergency Contact Information 1:
Photo release
Contact Name:
Occasionally IFE participants may be photographed in program
activities for use in International Education documentation and Relationship to you:
marketing. Photographs may be used in newsletters, newspapers, on
web sites and in other marketing and impact reports. Address:
May we take your picture for program documentation and marketing
purposes? Home Phone:
�Yes �No Initials Work or Cell Phone:
FERPA Release (Family Educational Rights and Privacy Act) E-Mail:
If you wish for the Office of International Programs to be able to
discuss any of the topics listed below with other designated
individuals, you must provide permission for us to do so in writing. Emergency Contact Information 2:
I give my consent to the Office of International Programs at Colorado Contact Name:
State University to release the following personally identifiable
information from my education record to the person(s) listed below, Relationship to you:
for the purpose of keeping these person(s) advised of my health,
program, and/or safety while I am abroad. Address:

(Initial all that apply): Home Phone:

Work or Cell Phone:

Health information in the event that the Office of
International Programs is notified of a serious physical or E-Mail:
mental health condition or emergency.
Information in the event of a legal and/or disciplinary Background Check
situation abroad. Your participation in the program abroad may require a legal
Information regarding your program abroad. background clearance. The Colorado State University Police
Department will perform or refer you to an organization that will do a
Do Not release any information background check for a fee, if required. As a participant, you will be
responsible for paying this fee.
Name Relationship Phone Number
If you are a CSU student, complete this for the period of time
1. since you have enrolled at CSU:
2. Have you been convicted of a misdemeanor? yes no

3. Have you been convicted of a felony? yes no

This consent will remain in effect for three years from the date of Have you been on probation or done court ordered community
signature unless I provide International Programs with a written service? yes no
revocation of this consent. Are any disciplinary actions pending at CSU? yes no
If you have answered yes to any of these questions, please attach a
letter of explanation in a sealed envelope, marked confidential, with
Required Signature Date your biodata. This will be kept confidential.
Agreement: Signature:
I certify that the information submitted on this form as given above is
true and complete. I understand that as a participant in the program
abroad I shall be subject to certain rules and requirements of this I am participating in this program voluntarily, and I agree to abide
University and of cooperating organizations, which I agree to fulfill in all by all rules and regulations that pertain to students and/or employees
respects, subject to immediate dismissal from the program if I do not do of Colorado State University, as described in the CSU Student Conduct
so. I agree to assume financial responsibility for the program fees and Code http://www.studentaffairs.colostate.edu/policies.aspx and to
for my own welfare while abroad. I understand that the International follow instructions and guidelines from the group leader(s)for the
Education reserves the right to cancel, alter or amend any part of any duration of the program.
program or to increase charges should circumstances make these actions
advisable or necessary.

Signature Date
Signature Date

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