Student Exchange Information And Consent Form
Complete this form to provide student exchange participant details, program preferences, emergency contact information, and the required exchange participation acknowledgment.
Participant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender / Pronouns
Please Select
Female
Male
Non-binary
Prefer to self-describe
Prefer not to say
Current School/University Name
*
Current Grade/Year or Academic Level
*
Please Select
Primary School
Middle School
High School
Undergraduate Year 1
Undergraduate Year 2
Undergraduate Year 3
Undergraduate Year 4
Graduate
Postgraduate
Other
Home Country
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Exchange Program Details
Host Institution or Destination School Name
*
Destination Country / City
*
Exchange Program Name or Cohort
*
Planned Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Planned End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Accommodation Preference
*
Host Family
Dormitory/Residence Hall
Self-Arranged
Other
Special Academic / Program Notes
Emergency and Safety Information
Emergency Contact Full Name
*
First Name
Last Name
Relationship to Student
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Allergy or Relevant Health/Safety Note for Exchange Participation
Submit
Should be Empty: