ࡱ> _ $-bjbj;`;` DY 7\Y 7\$@VVVVVjjj8\<j_:: T09999999$S< ?:VTT:VV 4: VV 9 9 57#aFZ69/:0_:r6\?r?07?V7 ::Pr_:?> : DOMESTIC & INTERNATIONAL TRAVEL APPLICATION FORM Washtenaw Community College Applications can be found on the Intranet in the International Folder Please Print I. COURSE/PROJECT INFORMATION Title of domestic or study abroad experience_______________________________ Name of project leader __________________________________________________ C. Contact information for project leader Department ________________________________________________________ Address ________________________________________________________ Phone ____________________ Email ____________________ D. This project will be organized (please check one):  FORMCHECKBOX  Primarily through  FORMCHECKBOX  Through another organization (e.g. another higher education institution study abroad program) If organized through another group, provide contact information below: Institution _________________________________________________________ Contact _________________________________________________________ Address _________________________________________________________ Phone _____________________ Email _____________________ E. Names(s) of any other individuals helping to lead/organize project ( or external) Name _________________________________________________________ Institution _________________________________________________________ Name _________________________________________________________ Institution _________________________________________________________ F. Primary location of project Country ________________________ City __________________________________ Institution(s) (if applicable) __________________________________________________ Other locations included in project, if any: _________________________________________________________ G. Anticipated dates of project Semester __________________________ Year________________________________ Travel dates__________________________ II. COURSE/PROJECT INFORMATION Please complete and submit Attachment A(Travel Itinerary, Transportation, and Housing Plan) Brief description of the proposed experience and rationale/merits for travel. (If this class or project is coordinated through an organization other than , please attach copies of program materials) This class or project is (please check):  FORMCHECKBOX  for credit  FORMCHECKBOX  non-credit (go to item F)  FORMCHECKBOX  professional development (go to item F) C. This experience is part of (please check): (All new courses/changes must comply with standard procedures and timelines)  FORMCHECKBOX  an existing credit course  FORMCHECKBOX  a new credit course Course number and title _______________________________________________ D. Course/Project Outcomes (list as many as necessary; attach Master Syllabus for credit courses) 1. 2. 3. 4. 5. Is this course part of a academic degree/certificate program? (All program changes must comply with standard procedures and timelines)  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, provide program title ________________________________________ Target audience for class or project (e.g. general student audience, students in a particular discipline or course, faculty/staff, community members): Please note that students must be 18 or over to participate in study abroad experiences. Estimated number of participants (including any faculty/staff leaders): ______________ Language proficiency requirements Is knowledge of a foreign language necessary for successful participation in this class or project?  FORMCHECKBOX  FORMCHECKBOX  Yes  FORMCHECKBOX  No (go to item I) Language required __________________________________________________ Level of proficiency required (e.g. completion SPN 111):___________________________ Describe how participants will obtain/demonstrate required proficiency: Please describe any other special requirements or issues that might affect participation in this experience (e.g. special visas, health or safety issues, proficiency in a discipline): III. PROJECT EVALUATION AND FOLLOW-UP A. Course/Project Student Learning Outcomes Assessment 1. Describe the evaluation process of this project that will ensure it is successful in meeting the course/project outcomes outlined in II E (attach master syllabus if appropriate). B. Follow-Up Describe how you and/or students plan to share your learning experience with the campus community. IV. FUNDING AND SUPPORT NEEDS FOR STUDY ABROAD CLASS PROPOSAL Please complete and submit Attachment B (International Travel Budget Form). Funding Summary (based on Attachment B) Estimate the amount of funds required for the proposed class or project $________ Expenses to estimate and consider for student and instructor participation: Estimated cost per participant $_________ Number of participants $_________ Estimated out-of-pocket costs per participant $_________ Total estimated cost of study aboard experience per student $_________ (Student costs should reflect instructors travel expenses) Amount of funding expected from sources outside (e.g. grant funding) $_________ Instructor needs to be aware of the following items that may require coordination: Travel arrangements Accommodations Visas/Passports Tour arrangements Meals It is recommended that you seek the assistance of a travel agency to coordinate the above items. does not provide staff to coordinate these details. V. OTHER INFORMATION If desired, add any other comments that would assist in reviewing this proposal. VI. CHECKLIST Please check that you have done the following before seeking final approval and submitting:  FORMCHECKBOX  I have completed and attached Attachment A:Travel Itinerary, Transportation, and Housing Plan  FORMCHECKBOX  I have completed and attached Attachment B:International Travel Budget Form  FORMCHECKBOX  I have checked the US Department of States website and confirmed that there are no Travel Alerts or Travel Warnings for the proposed destination(s). Please note that the college does not support travel to areas under such alerts/warnings. Status of such alerts/warnings will be rechecked closer to departure. Please see: http://travel.state.gov/content/passports/english/alertswarnings.html VII. Dean/Chair Approvals ___________________________________ __________________________ Print name (Department Chair) Department ____________________________________ ___________________________ Signature Date ___________________________________ __________________________ Print name (Dean) Division ____________________________________ ___________________________ Signature Date If application involves an additional department and/or division, please have the second Chair and Dean (if applicable) acknowledge their approval of the application. ___________________________________ __________________________ Print name (Department Chair) Department ____________________________________ ___________________________ Signature Date ___________________________________ __________________________ Print name (Dean) Division ____________________________________ ___________________________ Signature Date Please return completed proposals to SC 271. If you have questions, contact Julie Morrison at x5010 or jmorriso@wccnet.edu Attachment A: Travel Itinerary, Transportation, and Housing Plan TRAVEL ITINERARY Please provide a brief draft travel itinerary below according to the sample provided.SAMPLE: June 21, 20xx June 22 June 26 July 4 July 6  Depart DTW Arrive Paris for culinary studies at institution X Travel to Loire for study at X Return to Paris Depart Paris/Arrive DTW Date Activity   TRANSPORTATION and HOUSING Provide a brief draft plan for travel and accommodations. Transportation: Include travel to and from host country as well as in-country travel (e.g. mode of travel) and who will arrange (lead faculty, student, travel agent). Housing/Accommodations: Briefly describe planned accommodations for travel destination(s) (hotel, dorms, host families, etc.) and who will arrange (lead faculty, student, travel agent)..   Attachment B: International Travel Budget Form Please note when completing: 1 .Budget is intended to give an estimate of the cost of the trip 2. Add items as necessary 3. Student fee should factor in the instructors expenses Expense CategoriesEstimated Cost/Instructor# Students Required to Hold the ClassEstimated Cost/Student (cost of expense divided by # students in program)Travel Airfare (example) Shuttle Rental car(s) Train Misc. (please specify)Total TravelLodging Hotel/B&B/Hostels DormTotal Lodging Tickets/admissions fees Museums Entertainment (opera, theater) OtherTotal TicketsFood (per traveler) Breakfast Lunch Dinner Total FoodTravel Insurance*Misc. ExpensesEstimated cost of trip/students enrolled$.................... * provides basic health insurance to travelers at no cost. It is strongly recommended each traveler purchase travel insurance in addition to the college-provided insurance.      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