International Exchange Student Application Student InformationInformation must match your passport. Last Name/Family Name * First/Given Name * Middle Name Date of Birth (Month, Date, Year) * Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 Gender * Male Female Marital Status * Single Married Contact Information Mailing Address * City * State/Province * Country * Postal Code * Home Phone * Email Address * Cell Phone Citizenship * Country of Birth * Country of Legal Permanent Residency * City of Birth * Home Institution Information Name of Home Institution Address Major Classification International Office Point of Contact Name Title Phone Email Academic Advisor's Information Name Title Phone Email Proposed Studies at Mississippi College Anticipated Date of Entry Fall Semester Spring Semester Field of Study at Mississippi College Program Length One Semester Two Semesters Level of Study Undergraduate Graduate Financial InformationProof of Funding must accompany this form. All amounts must be in US Dollars. Please indicate both the name (source) and amount for each item in this section. Funding provided by Mississippi College Funding provided by Home Institution Funding provided by Home Government Funding provided by U.S. Government Personal Funds All Other Funding Medical ConsentIn case of a serious illness or accident, I give Mississippi College or its representative (s) permission to secure medical and/or surgical care to include; transportation to a doctor or hospital of their choice, injections, examinations, medication and surgery that is considered necessary for my good health. I agree to pay all off campus medical costs. In the event of a condition requiring minor care, I approve of care under a physician. In addition, I understand that I must purchase health insurance in the U.S. through Mississippi College. Mississippi College has permission to communicate at any time with my parents and/or sponsor concerning my academic performance and issues related to my health. Electronic Signature * Full Legal Name Emergency Contact Name Relationship Phone Conviction Statement Have you ever been arrested/convicted for anything other than a minor traffic violation? * Yes No If yes, date and nature of offense. Student Agreement I affirm that the information given in this application is accurate and complete to the best of my knowledge. Mississippi College is a Baptist institution and does not permit possession of or use of alcohol or drugs while enrolled. If admitted to Mississippi College, I agree to conduct myself in accordance with the high standards of Mississippi College and to abide by the policies and provisions stipulated in the College Bulletin, Student Handbook and/or other official College publications. Full Name (Printed) * Electronic Signature * Full Legal Name Electronic Signature of Parent or Guardian if student is under 18 * Full Legal Name Date * Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 Upload Documents Here - Please save your forms as Last Name - Document Type (Language, Transcript, Passport, etc.) Select File : Cancel
