Grand Valley State University Exchange Program Application

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Dependent
Relationship to Student Dependent First Name Dependent Middle Name Dependent Last Name Dependent Citizenship Dependent Birth Place Dependent Birth Date Dependent Birth Date Dependent will be: Dependent will be: Entering the U.S. with me Entering the U.S. Separately

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Part IV. Documentation of Financial Support

Federal regulations require us to obtain from you a certification that you have adequate financial resources to meet all expenses related to your program.

Identify below the sources of funding available to you for the period of your stay. Identify each source of funding that applies and the amount of financial support provided. For sources of funding other than this institution, please provide evidence of support(List amounts in U.S. currency).
Please submit a bank statement of proof of loan approval to cover your expenses while at GVSU. If the bank statement is not in your name, we will need a letter of support from the person whose bank statement you are providing.

Support Sources

Government

Exchange Visitor's Government

Amount

Personal

Amount

Other

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Source Amount

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Are all of the accounts in your name?

Yes

Part V. Insurance Requirement

As a GVSU J-1 Exchange student, you are required to purchase our medical health insurance policy for the duration of your exchange program in the USA. This policy, brokered by LewerMark, meets the U.S. Federal Regulation standards that are required of all J-1 Exchange students. The policy rate for Winter 2024 semester is $903.12 and will be billed to your GVSU Student Account. Details about the policy are available on our website: https://www.gvsu.edu/istudents/lewermark-health-insurance-130.htm.

Part VI. Signature

Your signature below signifies that the information you have provided on this form is complete and accurate to the best of your knowledge and that you authorize GVSU to communicate with your home institution about your academic progress and performance.

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Today's Date

Part VII. European Union Data Protection Policy

GDPR Privacy Notice and Request for Consent
The European Union General Data Protection Reculation, or GDPR (EU 2016/679), is a regulation concerning the collection, protection and processing of personal data provided by an individual ("data subject") wile in a European Union Member State, regardless of citizenship or residency. Therefore, the terms and conditions contained in the Regulation and detailed in this Notice only apply while an individual is physically present in one of the EU Member States. Complete information is available on the European Comission website.

Privacy Notice
Grand Valley State University continues to be committed to conducting the collection and processing of personal data with integrity and in compliance with applicable data protection laws. This privacy notic, required under the GDPR, presents information about how the University collects, uses and protects personal data you provide as an International student.

A. Data Controller Contact Information Grand Valley State University serves as the Data Controller and determines the purposes and means of processing your personal data. The individual below serves as the primary contact for GDPR compliance related to international student information and is responsible for responding to questions about this Notice and requests to exercise a data subject's rights.

Name: Libby Jawish
Department: Padnos International Center
Title: Director of International Student and Scholar Services
GVSU Address: 130 Lake Ontario Hall, 1 Campus Dr, Allendale, MI 49401
Email: istudents@gvsu.edu
Telephone: 616331 3898

B. Purposes for Collecting and Using Data Your information is collected and used to report your information and status to USCIS, Social Security Administration, Relation Health Insurance, other GVSU departments.
C. Sharing and Transferring Data Your information is collected and used to report your information and status to USCIS, Social Security Administration, Relation Health Insurance, and other GVSU Departments.
D. Data Retention Data is retained in accordance with University policy and as required under applicable U.S. laws and regulations.
E. Sensitive Data Your personal identifying information, such as passport, birth date, country of birth, names of family members are collected in order to provide services required by federal law or in order to provide assistance to you in case of an emergency.
F. Rights of the Data Subject While in the EU you will be able to exercise your rights as a data subject described in Article 15-22 of the GDPR: right of access to your personal data, right to correct that data, right to have the data erased, right to restrict processing, right to data portability, right to object to processing, right to withdraw consent, the right not to be subject to automated decision-making, and the right to lodge a GDPR-related complaint with an EU Supervisory Authority. Please note that the University is subject to federal and state laws, including but not limited to the Family Educational Rights and Privacy Act, that may require that we request, process, retain, and report on certain types of data. These legal obligations may also affect actions we would be permitted to take in response to a request to exercise your GDPR data rights, especially the right to have your data erased.
G. Importance of Data Failure to report the the data will likely result in non-compliance of the Department of Homeland Security regulations
H. Data Protection The University has put in place reasonable physical, technical, and administrative safeguards designed to prevent unauthorized access to or use of information collected online.

Request for Consent

Please reread the above Notice and agree to the conditions in order to be permitted to be enrolled at Grand Valley State University.

I consent to Grand Valley State University's use of my personal data (including sensitive data) for the purpose outlined in this Notice, as well as for the transfer of my personal data between the European Union and Grand Valley State University and its representatives, pursuant to the conditions and limits specified in the EU GDPR. I also hereby waive any right to privacy and confidentiality regarding the University's reporting to the appropriate authorities if I am seriously ill; suffer an injury; or am the victim or perpetrator of harassment, whether on- or off-campus

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Admissions & Recruitment

Grand Valley State University Exchange Program Application

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