GADSDEN STATE COMMUNITY COLLEGE

I N T E R N A T I O N A L P R O G R A M S
P.O. Box 227 - Gadsden, Alabama 35902-0227 (256) 549-8324 - Fax (256)549-8344

AFFIDAVIT OF FINANCIAL SUPPORT

SUBMIT COMPLETED . FORM TO:
INTERNATIONAL PROGRAMS OFFICE, GSCC
P.O. Box 227, Gadsden, Alabama 35902-0227
International students or their sponsors must provide evidence of sufficient funds available to support financially two semesters of study at
Gadsden State Community College. This affidavit must be signed by the sponsor and stamped or sealed by a notary public, bank official or individual
authorized to certify documents. An original letter with an official signature on bank letterhead must also be submitted. The letter should verify
a current account balance and whether the account is in good standing. The sponsor must have a minimum income of $25,000 (U.S. dollars) per year.

Please Print

I, , who resides at
Name of Sponsor Sponsor Address

Sponsor Address Sponsor E-mail Address Sponsor Telephone Number

being duly sworn, depose and say that it is my intention to support

Name of Student

who resides at
Student Home Country Address

and comes to the United States to study at Gadsden State Community College
Student Home Country E-mail Address

and reside at (U.S. address, if known)

Student U.S. Address

Student U.S. Phone Number Student U.S. E-mail Address I

I am aware that Gadsden State Community College does not consider students registered for classes unless the student pays
all tuition and fees at registration.
I am willing and able to maintain and support the prospective student. This affidavit is made by me for the purpose of
assuring Gadsden State Community College that the student I am sponsoring will have sufficient funds to cover tuition, fees and
living expenses during his/her course of study and will not become a public charge during his/her stay in the United States of America.

Employer or source of income and net amount received per year in U.S. dollars.

$
Income per year

Relationship to student:
Mother Father Relative Friend Company Other

I certify that all information provided on this Affidavit of financial support is true and valid.

Signature of Sponsor Date

Signature and statement signed and sworn before me.

AFFIX STAMP OR SEAL

Signature of Notary Public, Bank Official

Address, Location

Date

An original official bank letter verifying sponsor's financial account information must be attached. These documents will not be
returned. We suggest that you request an additional copy to submit to the U.S. Embassy or Consulate with your visa application.
 ACCS Institution: __________________________________________

Medical History Form

This portion is to be completed by the student

Name
Last First Middle SS#/ID

Home Address
Street City State Zip

/ /
Cell Phone Date of Birth Male Female

Emergency Contact Phone Relationship

This medical data is necessary to serve as a baseline for medical clearance for actual enrollment. Details of abnormalities
should be recorded. Please check YES or NO to the following conditions.

CONDITIONS NO YES
Hypertension
Rheumatic fever or heart trouble
Liver trouble or jaundice (Hepatitis)
Asthma or tuberculosis
Major surgery or injury
Ulcers or gastroenteritis
Backache or joint trouble
Kidney trouble
Diabetes
Severe headaches
Epilepsy or convulsions
Dyspnea
Drug or alcohol problem
Has applicant been treated for any emotional disorders?
Has applicant, because of his/her health, withdrawn from college? If so explain
Does the applicant have any illness or medical condition that requires regular treatment?
Does the applicant miss school regularly or frequently due to any physical condition?
Has the applicant been hospitalized?
Any family member with chronic illness, mental or nervous disorders?
Anemia
Learning disability

Comments:

Present Health: Good Fair Poor Date of last exam: / /

Complete and return to:

 ACCS Institution: __________________________________________

This portion is to be completed by a Physician.

Height Weight Skeletal Size: Small Medium Large EL

B/P Pulse Respiration Temperature

Laboratory Findings

Hemoglobin or Hematocrit WBC Serology

Urine: Sp.Gr Alb Sugar

Eyes Ears
Do you wear glasses? No Yes Hearing normal? No Yes
Do you wear contacts? No Yes Are drums intact? No Yes
Distant Vision Without glasses R20/
With glasses R20/
Near Vision Without glasses R20/
With glasses R20/

Head, Neck and Face Normal ( ) Abnormal ( )

Nose and Sinuses Normal ( ) Abnormal ( )
Mouth and Throat Normal ( ) Abnormal ( )
Teeth Normal ( ) Abnormal ( )
Lungs and Chest Normal ( ) Abnormal ( )
Heart Normal ( ) Abnormal ( )
Vascular System Normal ( ) Abnormal ( )
Abdomen Normal ( ) Abnormal ( )
Endocrine System Normal ( ) Abnormal ( )
Female: Breast Normal ( ) Abnormal ( )
Female: Pelvic Normal ( ) Abnormal ( )
Male: Genital Normal ( ) Abnormal ( )
Male: Hernia Normal ( ) Abnormal ( )

Present Health: Good Fair Poor Date of exam: / /

I certify that the above information is true.

Physician’s Signature Student’s Signature

TO BE COMPLETED BY COLLEGE OFFICIAL

Date Received: ___________________

Complete and return to:
Signature: _____________________________________
 ACCS Institution: __________________________________________

Immunization Form
To ensure the health and safety of our campus, immunizations against communicable disease is extremely
important. Vaccination against Measles, Mumps, Rubella (MMR), Tetanus, and Meningococcal is required, as
well as a negative Tuberculosis skin test. This is a requirement for all International Students. This form must be
completed and submitted prior to admission in any ACCS institution.

Name
Last First Middle SS#/ID

Address
Street City State Zip

Date of Birth / / Contact Number Email

Section A: Required Immunizations/Tests

Month/Day/Year Month/Day/Year

1. Meningitis Vaccine- within the last 5 years (Menomune, Menactra, Menveo)

2. Measles, Mumps, Rubella (MMR)
3. Tetanus

4. Tuberculosis Screening
Date Placed Date Read MM Neg Pos
TB Skin Test by PPD
Date Result
Chest X-Ray (if positive PPD or lab) Submit copy of chest X-ray report

Section B: Recommended Immunizations

Please attach documentation of all childhood vaccinations (copy of Blue Card)
Month/Day/Year Month/Day/Year Month/Day/Year Titer Date & Result
TD (Tetanus/Diphtheria) Do not write here Do not write here Do not write here
AND/OR Tdap (Tetanus/Diphtheria) Do not write here Do not write here Do not write here
Polio Do not write here Do not write here
Hepatitis B
Varicella (Chickenpox) Do not write here

I certify that the above dates and vaccinations are true.

Signature of License Health Care Professional or Authorized Individual Date

Complete and return to: