Visiting Student Application

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Visiting Student Application

Type of Application*

New Applicant Extension with existing department

New End Date

Department Applying to - test

Department Applying to*

Name*

First Name

Middle Name (optional)

Last Name

Date of Birth*

Age

Gender*

Male Female

Are you a U.S. Citizen or Permanent Resident?*

Yes No

Visa Type*

Status*

Country of Origin*

Last 4 of SSN*

Mailing Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Phone*

Email*

Home Address 1*

Home Address 2

City*

State*

Zip Code*

Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Home Institution (University/College or High School)*

By checking this box, you acknowledge that your visiting student records are subject to the Family Educational Rights and Privacy Act (FERPA). Your acknowledgement of this statement, and signature on this form, permits UT Health San Antonio to exchange educational records relevant to your visit at UT Health San Antonio with your home institution, to include academic related information. Exchange of visiting student records under this agreement will not require a separate consent.*

I agree

Visiting Student Signature*

[clear]

Use your mouse or finger to draw your signature above

For All Visiting Students:

All Items in this area must be completed for the application to be accepted.

Visiting Student has submitted and passed background check (HOP Policy 4.4.1).*

Visiting Student has provided required immunization records.*

Visiting Student has malpractice insurance, if needed.*

Visiting Student has health insurance.*

Visiting Student has acknowledged contents of Confidentiality of Patient Health Information Policy (HOP Policy 11.1.6).*

Visiting Student has completed Title IX training (HOP Policy 4.2.2).*

Visiting Student has completed any additional training(s) or acknowledgement(s) required by the Sponsoring Department.*

Visiting Student has submitted completed Visitor application and paid processing fee(s).*

For Visiting Students Receiving Credit:

If Visiting Student is receiving academic credit at their Home Institution for their experience at UT Health Science Center San Antonio, the Visiting Student and Sponsoring Department are aware that the Office of the University Registrar does not transcript this experience and all paperwork/ documentation needed for credit must be tracked and provided to the Home Institution by the Sponsoring Department.*

For Minors

Visiting Student has completed Minors in the Research Workplace Compliance & Safety Requirements (Policy 8.11.1).

Payment

Who is paying the application fee?

Student Department

Department PID*

Please send the student this link to Pay

For International Visiting Students:

Visiting Student has provided copies of immigration documents to the Office of International Services.*

Application Payment

Student Group*

Received Payment *

Yes No

Process Complete and all Data Entered into the appropriate System*

Yes No

Date and Time of completion*

Visiting Student Application

Part II: (required) To be Completed by Sponsoring Department

For All Visiting Students:

For Visiting Students Receiving Credit:

For Minors

Payment

For International Visiting Students:

Application Payment