Fill - Free fillable Office of Internat ional Programs Application to Participate (Muskingum College) PDF form

Do you have a passport? NO

YES (a copy of the passport should be attached.)

Pass

port #: _______________________ Issuing Country: _________________________

Expires: __________

Health Insurance Information

Health Insurance Company: _____________________________________________________

Group #: ______________________________ Member #: _________________________

Member’s Name: _____________________________________________________________

Medical History

Primary Doctor: ________________________ Phone #: ___________________________

Allergies: ___ medication(s): ___________________________________________________

___ food(s): _________________________________________________________

___ environmental (including animals or insect stings): _______________________

_______________________________________________________________

Office of Internat

ional Programs

Application to Participate in International Programs

Personal Information

Name: __________________________________________ ID# ____________________

Home Address: _______________________________________________________________

City: __________________________________________ State: ________ Zip: __________

Phone number where you can be reached: ___________________________ (cell/home/work)

Educational Information

Name of study abroad program: __________________________________________________

Beginning date of program: _________________ End date of program: _________________

Number of credits you plan to take: ____________ per semester quarter

Current major(s): _____________________________________________________________

Current minor(s): _____________________________________________________________

International Experience

Please describe any international experience you have. _______________________________

____________________________________________________________________________

Non-Exchange Program

Please indicate if you currently have or have been treated in the past for any of the following

conditions or health concerns.

___ Alcohol/Chemical dependency ___ Heart disease

___ ADD/ADHD ___ Hepatitis

___ Anxiety/Depression ___ High blood pressure

___ Asthma ___ HIV+/AIDS

___ Chronic disease ___ Psychological/Psychiatric issues

___ Diabetes ___ Tuberculosis

___ Headaches/Migraines ___ Other medical concerns

Surgical history: ______________________________________________________________

____________________________________________________________________________

Current Medication(s): _________________________________________________________

____________________________________________________________________________

Additional information we should know: ____________________________________________

____________________________________________________________________________

Emergency Contacts

Name: ________________________________ Relationship to you: ____________________

Address: ____________________________________________________________________

City: __________________________________ State: ______ Zip: _________________

Phone # 1: ___________________________ Phone # 2: _____________________________

ame: ________________________________ Relationship to you: ____________________

Address: ____________________________________________________________________

City: __________________________________ State: ______ Zip: _________________

Phone # 1: ___________________________ Phone # 2: _____________________________

References

References may not be friends or family members.

At least one should be a Muskingum University faculty member.

Name: ____________________ Phone: _____________ Email: ______________________

____________________________________________________________________________________

For Office Use Only

Good academic standing: ______ GPA: _______ Class rank: _______ Good conduct standing: ______

Immunization record received: _____ Valid passport: ______ Application Approved: ______ By:______________________

AGREEMENT, WAIVER, AND RELEASE

Students must read and complete this Waiver and Release prior to participating in any travel associated

with Muskingum University’s International Programs. I, the undersigned, agree to the following:

(1) I shall indemnify Muskingum University (“University”) and hold harmless its agents and its

employees from all liability, losses, costs, claims, damages, and expenses, including attorney’s fees,

arising or claimed to have arisen out of personal injuries or death, or property damage or loss,

sustained by me as a result of participating in this academic, athletic, or University-supported

activity, however caused, including, without limitation claimed sole, joint, or concurrent negligence,

negligence per se, statutory fault, or strict liability on the part of University employees, other

participants, or third parties. In addition, I shall indemnify the University, its agents and employees

from all liability, losses, costs, claims, damages, and expenses, including attorney’s fees, relating to

claims or injury arising from my own negligence or intentional acts during my participation in this

International Program (including travel to and from any activity sites) and I hereby RELEASE and

forever DISCHARGE the University and its agents and employees from all such liability, loss, costs,

claims, damages, or expenses.

(2) I understand that the employee(s) for the activity are acting in their respective capacities as agents

of the University, not individually, and hereby waive any and all claims I may have or purport to

have against the University or against employee(s) individually including but not limited to any

losses occasioned by any changes in travel plans, weather, strikes, acts of God, force majeure, war,

terrorism, quarantine, criminal activity, or for the failure of any of the companies providing

transportation, lodging, meals, tour services, or other goods or services, as applies to the nature of

this activity, to provide such services on a timely basis or for the failure to provide them at all.

(3) I understand that most, if not all, of the premises, facilities, and/or equipment used as part of the

program(s) are not owned, maintained, or controlled by the University, but rather by the premises

owners. There may be other risks not known to the University and not reasonably foreseeable at

this time. I waive any and all claims I may have or purport to have against the University including,

but not limited to the following: (a) the use and condition of various modes of transportation,

premises, facilities, and equipment; or (b) the inadequacy or unavailability of medical facilities,

treatment, and/or professionals.

(4) Program Modifications/Cancellations.

(A) The University has the right to make cancellations, changes, or substitutions in the course,

agenda, program, assigned employee(s), travel arrangements, or arrangements for other

services, in the event of causes beyond its reasonable control, significantly changed

conditions, or changes in the interests of the group. Such causes may include, but are not

limited to, travel alerts or warnings issued by the U.S. Department of State, suspicion of

terrorist activities, or general health or safety concerns.

Office of International Programs

(B) The University may, but is not required to, advise me of any health or safety concerns of which

it may become aware. It is my responsibility to inquire about safety or health dangers

prevalent at the site of the program activities or which may be encountered in travel to or

from such location, including consulting a physician and/or the Center for Disease Control.

Program. While the University may assist in any reasonable manner

should such a condition exist, being released from any quarantine or incarceration is my

responsibility, and the University bears no liability for any such circumstance.

(5) Financial.

(A) The University may charge a reasonable fee to compensate itself for any significant change in

currency exchange rates or for unanticipated increases in the cost of providing the full services

of the International Program. At the election of the University, it may declare any exchange

rate to be commercially impracticable and may cancel any program at any time without

liability to participants or prospective participants.

(B) I know all deadlines for payment and cancellation. I understand that if I cancel my anticipated

participation in the program after those dates, I will not be entitled to a refund of any money

I have deposited or paid. All cancellations must be submitted in writing to the Director of

International Programs.

of the program, the University may cancel my participation in the program, and I will be

refunded according to the program guidelines.

(D) If I am participating in a non-exchange program, I must pay all fees to the host institution or

a third-party provider. I will not pay any fees to Muskingum University during the time I am

enrolled in a non-exchange International Program.

(E) I understand that my financial aid package may change based on the International Program

that I select. I will discuss financial aid with the Director of International Programs.

(6) Personal Property. I am solely responsible for obtaining and keeping safe my personal possessions,

documents, money, travel tickets (as needed), and other property. I hereby WAIVE and RELEASE

the University, and any assigned employee(s) from any and all claims for expenses or losses of any

nature and amount due to my failure to do so.

(7) Medical.

(A) In the event of illness or injury requiring medical care, I hereby authorize the University’s

employee(s) to contact emergency services, if needed, or transport me to an appropriate

medical facility, if requested, and to release health and medical information disclosed on my

Application to Participate in International Programs.

(B) I authorize University employee(s) to notify my emergency contact(s).

treatment. I am responsible for obtaining and keeping in force adequate health insurance

while traveling, which provides coverage for illnesses or injuries I sustain or experience while

abroad; and, more specifically, in the countries where I will be living and/or traveling. By my

signature below, I certify that I have confirmed that my health insurance policy will adequately

cover me while I am outside of the United States. In addition, I agree to provide the University

with written proof of such insurance if it is requested. I understand and agree that I am

financially responsible for my own medical expenses, and that any advance medical payment

made by the University through the employee on my behalf shall be reimbursed to the

University immediately.

(D) I am responsible for obtaining and paying for any immunizations required for travel. I will

provide proof that all required immunizations are up to date to the Director of International

Programs and understand that my travel and program may be canceled if I do not provide

adequate documentation.

(8) Behavioral Expectations.

(A) While participating in an International Program, I am personally responsible for the success

of the program. I will exercise good judgment, respect the rights of others, and abide by the

laws and customs of the host country and any other country that I visit or travel through.

(B) I will adhere to the policies of the host university.

of its provisions, as well as all of Muskingum University’s rules and policies, including, but not

limited to, the Code of Student Conduct, the Gender-Based and Sexual Misconduct Policy, and

all Academic Policies and Procedures from the Muskingum University Catalog.

(D) I understand that violating conduct policies may result in my removal from the International

Program, as well as disciplinary action upon my return to Muskingum University. I am

responsible to pay any expenses incurred because of my actions and/or as the result of my

removal from the International Program.

(9) Academic Expectations. I will participate in all classes and scheduled activities unless I am ill. I will

keep the Registrar or Director of International Programs informed about my academic progress. I

will request a transcript to be sent from the host institution to Muskingum University in a timely

manner.

(10) Applicable Law and Severability. I agree that this Agreement is to be construed under the laws of

the County of Muskingum, State of Ohio, United States of America; and that if any portion of the

Agreement is held invalid, the balance of the Agreement shall, notwithstanding, continue in full

legal force and effect.

I have read and understand this Agreement, Waiver, and Release and agree that it will legally bind me,

my heirs, successors, assigns, personal representatives, and my estate.

___________________________________ ___________________________________

Applicant’s printed name Date

___________________________________________ ___________________________________________

Applicant’s signature by: Director of International Programs

(or parent on behalf of minor Applicant) Muskingum University

Facul

ty Form

Personal Information

Name: __________________________________________ ID# ____________________

Home Address: _______________________________________________________________

City: __________________________________________ State: ________ Zip: __________

Phone number where you can be reached: ___________________________ (cell/home/work)

Medical History

Primary Doctor: ________________________ Phone #: ___________________________

Allergies: ___ medication(s): ___________________________________________________

___ food(s): _________________________________________________________

___ environmental (including animals or insect stings): _______________________

_______________________________________________________________

Please indicate if you currently have or have been treated in the past for any of the following

conditions or health concerns.

___ Alcohol/Chemical dependency ___ Heart disease

___ ADD/ADHD ___ Hepatitis

___ Anxiety/Depression ___ High blood pressure

___ Asthma ___ HIV+/AIDS

___ Chronic disease ___ Psychological/Psychiatric issues

___ Diabetes ___ Tuberculosis

___ Headaches/Migraines ___ Other medical concerns

urgical history: ______________________________________________________________

____________________________________________________________________________

Current Medication(s): _________________________________________________________

____________________________________________________________________________

Additional information we should know: ____________________________________________

____________________________________________________________________________

Office of International Programs