UMass Lowell

Global Entrepreneurship and Innovation Workshop

Application - International Participants
Ashwin_Mehta@uml.edu

Manning School of Business

Summer 2016June 13 - 24
Participant Information: (please print clearly)
Sponsoring Institute: __________________________________________________________________________
Name: _______________________________
(LAST Name)
Name should be consistent with passport
Educational background:
(check all appliacble)

____________________________
(first name)

________________________
(middle name if any)

Business _____; Engineering: _____; Science: _____; Health: _____; Computer Sc: _____;
IS: _____; Other: _____; (specify): ________________________________________________

Date of birth: __________________________________

DD/MM/YYYY
Country of Birth:_______________________________

City of Birth:____________________________________

Passport#: ____________________________________
Attach a copy of Passport Identification Page

Passport expiration date: ___________________________

DD/MM/YYYY

Email: _______________________________________
Marital Status: Married
Single
If married, will you be accompanied by family member?

Citizenship: _____________________________________

Cell phone#: _______________________________

Gender: Male

_____

Female

Preferred Mailing Address: ___________________________________________________________________________

_________________________________________________________________________________________________
Home Country Address:_____________________________________________________________________________

Costs: Base Cost: $1,550 It includes Local Transportation, Housing, Meals and Program fee. Local Transportation
to and from Logan International Airport will be covered. Air travel, non-local US travel and other incidental expenses
are not in included in the base cost.

Please tell us about you

1. Have you attended any workshop or course related to entrepreneurship, innovation, etc.?
Yes ___; No ____
2. Do you have an Idea that you would like to work on during the Workshop?
Yes ___; No ____
3. If Yes,
a. Briefly describe:

b. Team members requirements (check all applicable):

i. Engineering ____
ii. Business ____
iii. Computer Science ____
iv. Health Sciences ____
v. Others _______________________________
vi. Do not know ____

4. Expectations (check all applicable):

a. Learn about Entrepreneurship ____
b. Help me start a venture ____
c. Experience diversity ____
d. Learn more about other disciplines ____
e. Learn more about other cultures ____
f. Need 3 credits ____
g. Other ________________
5.

Statement of Purpose
Attach a one-page, typed Statement of Purpose describing why you wish to participate in the Program and how it relates to your
academic plan, personal goals and career goals

Health Insurance Confirmation Coverage

Health Insurance Requirement - The recommended minimum health insurance coverage is as follow (the International Students & Scholars Office can
recommend US insurance providers if youre unable to obtain the proper insurance from your home country. You are required to have the minimum following
insurance coverage PRIOR to arriving in the U.S. The International Students & Scholars Office will request to see proof of this upon your arrival. The U.S.
Embassy may also ask to see proof when you apply for your visa. The minimum level of health insurance is as follows: At least $50,000 for Medical
Evacuation to the home country; At least $25,000 for Repatriation of Remains; $100,000 per accident or illness; A deductible not to exceed
$500 per accident or illness.

Instructions: As a participation in the program, you are required to obtain health insurance coverage for the duration of your time in the US.
Students with health insurance through a parent/guardian, or on their own, are responsible for verifying with their health insurance provider if
they will have coverage while in the US.

Please indicate your curent health insurance coverage below and complete the fields below.
Health care provider: ____________________________

Policy Number: ________________________________

Name of Subscriber: ____________________________

Relationship: __________________________________

Expiration date (if any): __________________________

Health Care and Special Needs Information

The study abroad experience is one that takes planning and preparation. It is important that health and/or special needs
information is provided well in advance. The following information will remain confidential and will not affect your eligibility
to participate in the study abroad program.
1.

Are you currently receiving any medical treatment or taking prescribed medications? If yes, please name the medication and briefly
describe the condition. Note: some medications may not be legal in your study abroad location .

Yes (explain below) No

2.

Have you ever or are you currently receiving counseling or psychotherapy, or being treated for any psychological or mental
conditions? If yes, please state approximate dates and briefly describe the reason
Yes (explain below) No

3.

Do you have a documented learning disability? If yes, please describe your disability and the accommodations you would need
during study abroad. Note: some accommodations may not be available.
Yes (explain below) No

4.

Do you have any dietary restrictions based on doctors recommendations? If yes, please describe.
Yes (explain below) No

5.

If there is any additional health information that would be helpful for us to be aware of during your travel, please describe below:

Communication Approval:
It is important that you communicate information to your parents/guardians about the study abroad program details, academics,
financial components, as well as your health and wellness arrangements that may need to be made before, during or after your
time abroad. There may be circumstances where a representative of UMass Lowell needs to discuss a variety of matters with
your parents or guardians. Please read the following statements and check the box regarding what information we can discuss
with parents/guardians.
Please sign below once you have checked and filled out the appropriate box.
Yes, I authorize the Office of Continuing Education, University officials and/or Faculty Leader(s) to communicate
with my parents/guardians/other (referenced below) regarding all issues involving my study abroad experience.
This may include, but is not limited to, student account information, student conduct issues, health and safety, or
academics. I expressly waive any privacy rights I may otherwise have under FERPA and HIPAA. Such contact may
occur before, during or after the program

Emergency Contact Information

Name

Relationship to you

Street Address

City

Home Phone

Work Phone

Cell Phone

Email Address

State

Country