Student Life Clearance Form

Student Life Clearance Form

All GU students applying to study abroad in any program(s) must receive clearance from the GU Student Life office.

Please complete the electronic form below. The information you provide will be directly submitted to the GU Student Life office for clearance. The Student Life office will answer the questions below and provide results to the GU Study Abroad office.

  1. Is the judicial/conduct file for this student clear? If "No", please answer the following:
    1. Have any previous notations/violations been dealt with and considered closed?
    2. Is the student currently under any judicial sanctions? Expiration: _________
    3. Has this student ever been involved in an incident that put themselves or others at risk?
    4. Has this student ever been on probation?
  2. Is the Student Life office aware of any concerns regarding social, behavioral or academic issues that might impact this student’s ability to study abroad successfully?
  3. Does this student have your approval to study abroad?
  4. Please add any additional comments you might care to make concerning this student’s eligibility and/or qualifications for study abroad, or for any clearance changes.
Do Not Edit:
Do Not Edit:
Do Not Edit:

Student Personal Information
GU ID Number
First Name:
Middle Name:
Last Name:
Cell Phone Number:
Your Email Address:
Your Current Class Status: Freshman Sophomore Junior Senior

Program Information

Name of First Program:
Location of Program
Term Applying To:
Spring 2010 Summer 2010
Academic Year 2010/2011 Fall 2010 Spring 2011
Name of Second Program:
Location of Program
Term Applying To:
Spring 2010 Summer 2010
Academic Year 2010/2011 Fall 2010 Spring 2011
Name of Third Program:
Location of Program
Term Applying To:
Spring 2010 Summer 2010
Academic Year 2010/2011 Fall 2010 Spring 2011

Complete the Following Question
Are there any factors - academic, social, emotional or behavioral - that might interfere with your success or be a challenge to you if you are allowed to study abroad?
No, there are no factors that might interfere with my success or be a challenge to me if I were allowed to study abroad.
Yes, there are factors that might interfere with my success or be a challenge to me if I were allowed to study abroad.
If yes, please explain below

Authorization To Release Information
Yes, I hereby waive my right to access information on this form and request that it be completed and forwarded to the GU Study Abroad office.

Acknowledgement
By typing my name and the date (MM/DD/YEAR) below, I acknowledge that even after Student Life clears me, any conduct violations prior to departure will place my participation in the requested program(s) at risk and may incur financial consequences.
Your full name:    Date (MM/DD/YEAR):