Green River Community College

International Student Application

For Green River office use only:
84492- ____________________ Received: _____________
Please submit your application to: Application Check List
International Programs
❏ Applicant must be at least 16 years of age by program start date
Green River Community College
❏ Completed application
12401 SE 320th Street
Auburn, WA 98092-3622 U.S.A. ❏ Financial statement – Official bank letterhead in English showing
enough funds for one year of study at Green River (see website
for current amount)
Fax: 1 - (253) 333-4940
❏ $50 non-refundable application fee
E-mail: [email protected]
Apply online: greenriver.edu/international ❏ Housing choice
Phone: 1 - (253) 288-3300 ❏ $300 Housing placement
E-Brochure: mi-america.com/grcc/welcome/index.php
❏ Copy of passport
IP Blog: insidegreenriver.com
❏ Transcript from last school attended, sealed by school
facebook.com/groups/64565165785/#!/GRCC.IP (highly recommended)
youtube.com/user/greenriverintlprgms
❏ For transfer students only: Transfer-In Form (available by request
twitter.com/grccip or on website)

Personal Information

❏ New ❏ Transfer ❏ Returning Green River / /

Date of birth: __________________________ ❏ Male ❏ Female
student student student month day year

Last name (family, as it appears on passport): __________________________________________________________________

First name (given, as it appears on passport): ___________________________________________________________________

Middle name(s), if any: ______________________________________

Country of birth: ___________________________________________

Country of citizenship: ______________________________________

Native language: ____________________________ English Ability: ❏ Fluent ❏ Average ❏ Poor

Visa Type: ❏ F-1 Student ❏ M-1 Student ❏ J-1 ❏ Other

Dependents arriving with you: ❏ Spouse ❏ Children

Do you have any medical conditions or allergies? ❏ No ❏ Yes, describe: __________________________________________

Do you require any special physical or learning assistance? ❏ No ❏ Yes, describe: ___________________________________

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Contact Information

Home country/current address: Emergency contact name and address:

_______________________________________________________ _______________________________________________
_______________________________________________________ _______________________________________________
_______________________________________________________ _______________________________________________
Phone: __________________________________________________ Phone: _________________________________________
E-mail: __________________________________________________ E-mail: _________________________________________
Where would you like your I-20 sent?
❏ Home country address ❏ Current address ❏ Agency/Advising Center (provide address below) ❏ Other (provide address below)
Agency/Advising Center or other mailing address (if applicable)
Agency Name: ______________________________________ Agency Contact Person: _______________________________
Address: _______________________________________________________________________________________________
______________________________________________________________________________________________
Phone: ________________________________________________________________________________________________
Fax: ___________________________________________________ E-mail:________________________________________

Financial Information

How will you pay for your tuition and living expenses?
❏ Personal funds ❏ Family funds ❏ Government sponsorship from home country
❏ Company sponsorship from home country ❏ Sponsor within the U.S. (I-134 required) ❏ Other ____________________
❏ I am including the following payments with this application (check all that apply):
❏ $50 Application fee is enclosed (non-refundable)
❏ $300 Housing placement fee is enclosed (refundable upon request up to 2 weeks before move-in day)
❏ Payment by credit card: ❏ Visa ❏ MasterCard Card Number: ____________________________________________________
Expiration Date: ________________

Name as it appears on the card:________________________________________________________________________________

Total charge amount (select one only)

❏ $50 (application fee only) ❏ $300 (Housing placement fee only) ❏ $350 (Both application and housing placement fee)
Signature of cardholder:___________________________________________________________________________________

❏ Payment by bank wire transfer to: U.S. Bank, 401-15th Street NE, Auburn, WA 98071
ABA No. 125000105
Student Name (must be included with wire information)
Green River Student ID Number (if known)
Green River Community College
International Account No. 153504623387
SWIFT code: USBKUS44IMT

Important! Send an e-mail to [email protected] with student name, date of birth, amount of money and date wired.

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Education

Are you a high school graduate? ❏ Yes ❏ No If yes, month and year of graduation: __________________________
Name of school you are currently attending or school last attended:____________________________________________________
TOEFL score: _____________ Date: ________________ IELTS score: ______________ Date: ________________
When would you like to start at Green River Community College?
❏ Fall/Sept. ❏ Winter/Jan. ❏ Spring/March ❏ Summer/June Year: ______________________________
What will you study? Check all programs that relate to your studies at Green River Community College.
You may check more than one box.
❏ University Transfer ❏ Intensive English (IESL) ❏ High School Completion Plus
❏ Associate Degree ❏ Certificate ❏ Special program, which one? _________________________
What subject (major) do you plan to study? ______________________________________________________________________
Approximately how long will you attend?
❏ 3 months/1 quarter ❏ 6 months/2 quarters ❏ 9 months/academic year ❏ more than 1 year
University Transfer Pathways: A letter of admission to a 4-year university may be requested at the same time you apply
for Green River Community College. See website at greenriver.edu/international/utp/index.shtm for the most recent
list of UTP universities.
❏ Yes – I request a UTP letter of admission to: ___________________________________________
Please fill in name of UTP university
Housing

❏ I will find my own housing (provide your U.S. address if known): __________________________________________________
Housing placements are made in the order completed applications and placement fees are received. Preferences are
met based on availability.
Green River has two housing choices for new applicants, Campus Corner Apartments or Homestay. What is your preference?
Choice #1: ________________________________________________________________
Choice #2: ________________________________________________________________

Homestay Applicants Complete This Section

This information will be provided to your prospective Host Family.

What type of family do you prefer? (You may check more than one box.)

❏ Family without children ❏ Family with international students ❏ Family with small children ❏ Family with teenagers

Are there foods you cannot or will not eat? ❏ Yes ❏ No What foods?__________________________________________

Do you smoke? ❏ Yes ❏ No ❏ Sometimes

Do you have any religious requirements or preferences?____________________________________________________________

Campus Corner Apartment Applicants Complete This Section

This information will be provided to CCA. Placements are made first-come, first-served. Preferences are met based on availability.

I prefer: ❏ Females only ❏ Males only ❏ No Preference

I prefer to share with: ❏ International students ❏ Domestic (American) students ❏ Both

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 Signature Page for Parents and Students
International Student Admission Policy

New students who use Green River’s I-20 to enter the U.S.A. must: Report in person to Green River’s orientation session for new international
students; Enroll for and attend the first quarter at Green River; Carry Health Insurance while enrolled at Green River; Present originals of:
passport, visa, and Green River’s I-20 - Students transferring from other U.S. schools must present their most recent I-20.

Medical Release

The undersigned hereby gives to Green River Community College, its officers, employees, agents, and host families full authority and permission
to take whatever action they feel is reasonably warranted under the circumstances, and to act as agent of the undersigned student and parent/
guardian, regarding the named student’s health and safety. This authority and permission includes, but is not necessarily limited to, the
following: Rendering or ordering medical treatment; the giving of medication; and any examinations, X-rays, anesthetic, medical or surgical
diagnosis or treatment or hospital care, if and as deemed necessary. The undersigned understands that a reasonable attempt will be made
to contact the undersigned parent/guardian before any action is taken. The undersigned agrees to be financially responsible for all medical
attention so authorized or ordered during the student’s attendance at Green River Community College. The undersigned represents that the
named student has no medical restriction that limits his/her full participation in the programs and activities of Green River Community College,
except as disclosed in any writing attached to this document. Permission is given for the student to participate in all activities offered at Green
River Community College, except as restricted in any attached writing. To the fullest extent permitted by law, the undersigned hereby releases
Green River Community College, its officers, employees, agents, and host families from all liability, and waive and release all claims, related to or
arising from such decisions or actions as may be taken under the authority of this document.

Photograph/Image Release

I consent to each use by Green River, and its officers, employees, and agents, of any photograph and likeness of me. Such use may include,
but aren’t limited to, use in a program, catalogue, schedule, newspaper, web site, brochure, advertisement, or other publication or recording
that describes, portrays, publicizes, or advertises the college or any college operation, and every reproduction, republication, or other re-use
of the same. I also hereby waive any right to compensation for such uses, and any right to inspect or approve the uses beforehand. I hereby
release Green River, its legal representatives and all persons acting under its permission or authority, from any liability by virtue of any blurring,
distortion, alteration, optical illusion, or use in composition form, whether intentional or otherwise, that may occur or be produced in taking of
said image.

By my signature below (Please check the following boxes):

❏ I verify that, to the best of my knowledge, all of the statements on this application form are true. I have read and agree to the
published International Student Admission Policies.

❏ I authorize Green River Community College to release academic records and immigration status information to my sponsor,
educational agency and or parents.

❏ I consent to use by Green River any likeness, image or photo of me for any official college program.

❏ I am either 16 or 17 years of age and understand that my parent/legal guardian will also sign this form before my
application is considered complete.*

______________________________________ ________ _______________________

Student’s Name (please print) Age Birthdate month/day/year

______________________________________ ________________________
Student Signature Today’s Date: month/day/year

______________________________________
*Parent/Legal Guardian’s Name (please print)

______________________________________ ________________________
*Parent/Legal Guardian’s Signature Today’s Date: month/day/year

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