Division of University Housing University of Wisconsin-Madison

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Division of University Housing

University of Wisconsin-Madison
2011-2012 University Residence Halls Application for Exchange Students

If you are interested in living in University Residence Halls for Fall 2011, we must RECEIVE your housing application no later than March 15, 2011. We may not be able to offer contracts to students who submit an application after March 15. NO DEPOSIT IS REQUIRED WITH THIS APPLICATION. Please mail, fax, or email application to:

Mail: University Housing

Slichter Hall – Assignment Office

625 Babcock Drive

Madison, WI 53706-1213

Attn: Kim Grocholski
Fax: 608-262-4082
Email: kim.grocholski@housing.wisc.edu
University Residence Halls

Most students who live in University Housing are 18-20 years of age. Students who apply for a University Residence Hall will be sent a preference form to rank their residence hall choices: Adams, Barnard, Bradley, Chadbourne, Cole, Elizabeth Waters, Friedrick Center, Kronshage, Merit, Ogg, Sellery, Slichter, Smith, Sullivan, Susan B. Davis, Tripp, and Witte. Please note that we are not able to guarantee a room assignment to a particular hall or to a single room. Most students are placed in double rooms with roommates. All of the University Residence Halls are smoke-free. Information about other housing options can be found at: http://www.housing.wisc.edu/universityapartments/ or http://campusareahousing.wisc.edu/

Requested Information -- Please Print Clearly
UW-Madison Campus Identification Number (if known):______________________________
Last Name:___________________________________________________________________
First Name: ___________________________________________________________________
Mailing Address:______________________________________________________________
Email Address:________________________________________________________________
Sex:  Female  Male
Birthdate (Month/Day/Year): _____/_____/_____
Duration of Stay:  Year  Fall 2011 only ($300.00 contract deposit will be forfeited)  Spring 2012 Only
Disability (Please specify any needs): __________________________________________

U.S. Exchange Coordinator: _________________________________________________

estimated budget 2011-12
University of Wisconsin-Madison, International Academic Programs

250 Bascom Hall, 500 Lincoln Drive, Madison, WI 53706

Tel: 608-265-6329 Fax: 608-262-6998 E-mail: abroad@bascom.wisc.edu

Estimated Expenses for Special Students 2011-12

Exchange Students must show evidence of the following amounts on their “Certification of Financial Support” document:

25 years old and under

26 years old and above

Fall 2011-12



Spring 2011-12



Academic Year 2011-12



DS-2019 Application for an Exchange Student

This form must be completed to request a DS-2019, Certificate of Eligibility for Exchange Visitor (J-1) Status. The University of Wisconsin-Madison will only issue a DS-2019 when Exchange Visitor (J-1) Status is requested for participation in a formal exchange program, by the student’s financial sponsor

(excludes personal/family funding), or if the student is currently in J-1 status.
The purpose of this request is to:
Begin a New Program (Applicant will enter the US from abroad.)
Personal Information (Please print clearly.)
Name: _______________________________________________________________________________________

Family First Middle

Gender:  Female  Male Birthdate: ______________________________________


City of Birth: ________________________________ Country of Birth: ________________________________

Country of Citizenship: ________________________ Country of Permanent Residence: ___________________

Intended duration of studies at UW-Madison: Year Fall Semester Spring Semester
Contact Information Position In Home Country

Present Mailing Address:  Undergraduate Student

 Graduate Student

___________________________________________ Expected graduation date: _______________________

Intended position at UW-Madison

___________________________________________  Undergraduate Student

 Graduate Student


E-mail: ____________________________________
Phone: ____________________________________
Fax: ______________________________________
Please contact your Exchange Coordinator if family [spouse and/or child(ren)] will accompany you to the US.
Return this application addressed to your Study Abroad Advisor’s attention:



Jessa Boche

Australia, New Zealand, United Kingdom

Erica Haas-Gallo

Austria, Germany

Kate Hamoonga

Denmark, Guatemala, TASSEP (Europe), South Africa, Sweden, Turkey

Erin Polnaszek

Brazil, Chile, China, Mexico, Thailand

Katie Saur

Montpellier exchange, Italy

Anna Seidel-Quast

France (except Montpellier exchange)

Lauren Worth

Czech Republic, Japan, Netherlands, Philippines, Singapore, South Korea, Taiwan

International Academic Programs (IAP)

250 Bascom Hall

500 Lincoln Drive

Madison, WI 53706


608-265-6329 (telephone)

University of Wisconsin-Madison, International Academic Programs

250 Bascom Hall, 500 Lincoln Drive, Madison, WI 53706

Tel: 608-265-6329 Fax: 608-262-6998 E-mail: abroad@bascom.wisc.edu

Date: ___________________ , 20______

I, __________________________­­­­­­­__________­­­­, will commit financial resources for my

Print full name of parent/guardian
son/daughter _____________________________________ in the amount equivalent

Print full name of student

of $___________ U.S.D. for study at the University of Wisconsin-Madison.

I understand that this document will be used as the basis for issuance of immigration documentation prepared by the University of Wisconsin-Madison, as required by the United States Department of Homeland Security (DHS).

______________________________ ­­­________________________________

Signature of Parent Signature and Seal of Bank Official

NOTE: A letter from your bank may be substituted for this document; however, the separate letter must be on letterhead and include the signature and seal of the bank official.

University of Wisconsin-Madison, International Academic Programs

250 Bascom Hall, 500 Lincoln Drive, Madison, WI 53706

Tel: 608-265-6329 Fax: 608-262-6998 E-mail: abroad@bascom.wisc.edu

To Whom It May Concern:

I give the Registrar’s Office of the University of Wisconsin-Madison permission to release one (1) copy of my official transcript to the International Academic Programs, 250 Bascom Hall.
I understand that once the grades are posted for the semester(s) in question, International Academic Programs will forward my official transcript to my home university.
Furthermore, if there are any holds on my academic record that prohibit the release of my transcript, it is my responsibility to clear the holds before leaving Madison. (Holds can be checked through My UW online.)
If necessary, I can be contacted at the following e-mail address after the end of the current term:


Signature Date UW-Madison Student ID#

Last (Family) Name (please print in BLOCK LETTERS) First Name (print in BLOCK LETTERS)

Health and wellness information
University of Wisconsin-Madison, International Academic Programs

250 Bascom Hall, 500 Lincoln Drive, Madison, WI 53706

Tel: 608-265-6329 Fax: 608-262-6998 E-mail: studyabroad@bascom.wisc.edu
Please return this form with your exchange application.

This required form is to be completed by the participant and is designed to help International Academic Programs (IAP) be of maximum assistance to you during your study abroad experience should the need arise. Mild physical or psychological conditions can become serious under the stresses of life while studying abroad. Thus, it is important that the program be made aware of any medical or emotional conditions, past or current, which might affect you in a foreign study context. The information provided on this form will be shared only with appropriate persons affiliated with your specific program and does not affect your admission into the program.

If you have any concerns about health conditions you may have while abroad, contact your IAP Exchange Coordinator and your healthcare provider as soon as possible. IAP will direct you to more specific sources of information about support services you can expect to find in Madison. Study abroad sites may not be able to accommodate all reported individual needs or circumstances. However, if you do not report a health condition, our ability to assist you in case of an emergency may be compromised.
IAP exchange student applications are not required to have a physical exam before coming to Madison. IAP strongly recommends that you have a physical exam, consult with your healthcare provider about immunizations and have a dental check up before departure. Consult your Exchange Student Handbook for additional health information.

NAME ____________________________________________ BIRTHDATE ____________ GENDER __________


HOME UNIVERSITY____________________________________________ TERM __________________________

Yes ____ No____ 1. Have you ever been or are you currently being treated for a physical health condition? (If yes, please explain.)

Yes ____ No____ 2. Have you ever been or are you currently being treated for a mental health condition (psychological or emotional)? (If yes, please explain.)

Yes ____ No____ 3. Do you have any allergies? (If yes, please explain.)

Yes ____ No____ 4. Are you taking any medications? (If yes, please explain.)
Yes ____ No____ 5. Have you had any major injuries, diseases or ailments in the past five

years? (If yes, please explain.)

Yes ____ No____ 6. Are you on a special diet (vegan, diabetic, vegetarian, etc.)? (If yes,

please explain.)

Yes ____ No____ 7. Is there any additional information that would be helpful for the program to be aware of during your study abroad experience? (If yes, please explain on the back of this form.)

I certify that all responses on this form are true and accurate, and I will notify International Academic Programs of any relevant changes in my health that occur prior to the start of the program.

Signature of Participant __________________________________________ Date ________________ , 20______
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