Domestic and International Travel
Please read this form carefully and be aware that by signing this form and participating in this university-
sponsored student travel, you will be waiving and releasing any and all claims that may arise as a result of your
participation in the university-sponsored student travel.
Student’s First Name: _______________________ Student’s Last Name: ____________________
RU Student ID#:___________________________ Dates of Travel: ________________________
Summary of Itinerary and Destination(s):
RU Sponsor(s): ____________________
Name of RU faculty-led program, if applicable: ________________________________________
If a parent/guardian signs this form because the participant is a minor or is otherwise not authorized to enter
into a contract, it is understood and agreed that the parent/guardian is making all acknowledgements and
affirmations on behalf of the participant, and the parent/guardian’s signature hereto shall bind both the
participant and the parent/guardian.
As a participant in a university-sponsored student travel described above (hereinafter the “Travel”), I recognize
and acknowledge that there are certain risks of injury, property damage, loss, emotional distress, and/or death
that may arise from my participation. I further recognize and acknowledge that Roosevelt University
(“Roosevelt”) and Travel sponsors/organizers cannot and do not guarantee my safety; ensure that American
standards of due process will apply in foreign legal proceedings; assume responsibility for my actions or the
actions of individuals who are not employed by Roosevelt or the Travel sponsors/organizers; or assume
responsibility for situations arising due to my failure to disclosure pertinent information.
(for out-of-state, overnight, or international travel only)
I affirm that my health is good, that I am fit to participate in any activities presented on this Travel. By participating in this
Travel, I voluntarily assume the risk of injury, property damage, loss, emotional distress, and/or death, including any
medical or other costs associated therewith. I hereby release, waive, discharge and covenant not to sue Roosevelt
University or any cooperating institution, or their respective trustees, officers, administrators, employees, agents,
representatives, volunteers, insurers, assigns, and successors (hereinafter referred to as “Releasees”) from any and all
liability, claims, demands, actions and causes of action for any loss, damage or injury, including death, that may be
sustained by me or my family, or to any property belonging to me or my family, whatsoever arising out of, related to, or in
any way connected with the traveling to or participation in the above-described Travel . I, and my agents, representatives,
assigns, heirs and successors hereby agree to indemnify, defend, and hold harmless Releasees from and against any and all
liabilities, losses, claims, demands, liens, damages, penalties, fines, interest, costs and expenses, whether known or
unknown, past, present or future, including, but not limited to, any and all costs, expenses, and attorneys’ fees, by reason
of injury, property damage, loss, emotional distress, and/or death arising out of, in connection with, or in any manner
related to the traveling to or participation in this Travel . It is my express intent that this Release shall bind the members of
my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be
deemed as a Release, Waiver, Discharge and Covenant Not to Sue the above named Releasees.
Compliance with Policies: I have read and agree to comply with all applicable University policies and procedures,
including but not limited to those that apply to my participation in the Program. I understand that permission to participate
in the Program may be suspended, revoked, or denied by the University in its sole and complete discretion.
Independent Activity: I understand that the University is not responsible for any loss or damage I may suffer when I am
traveling independently or when I am otherwise separated or absent from any University activity. In addition, I understand
that any travel I do independently before or after the University-sponsored Program is entirely at my own expense and
Standards of Conduct: I understand that each country, state, and city has its own laws and standards of acceptable
conduct, including attire, manners, morals, politics, alcohol and drug use, and behavior. I recognize that behavior that
violates those laws or standards could harm the University’s relations with those jurisdictions and the institutions therein,
as well as jeopardize my own health and safety. I, therefore, understand that I am responsible for becoming informed of,
and abiding by, such laws and standards. I understand that any violation of the foregoing disciplinary disturbances may
constitute grounds for my referral to the Universitys Office of Student Rights and Responsibilities, and possibly my
suspension or expulsion from the Program and/or from the University. In the event of a conflict between foreign
law/custom and University policy, including our Student Code of Conduct (e.g., as is the case where the legal drinking
age in another country may be age, but the Student Code of Conduct prohibits drinking under age 21), University policy,
including our Student Code of Conduct shall prevail.
I also acknowledge and fully understand that in the event I choose to extend my travel beyond (end date of Program,
including travel) or commence my travel prior to the start date of Program, or otherwise make any changes to the travel
plans arranged for the Program, I will be fully responsible for any such travel arrangements. Roosevelt University accepts
no responsibility for lodging, food, travel, or other necessities occasional by any changes made to the agreed upon travel
plans or any extension thereof.
(If travelling internationally, please read and initial each item below. This section does not apply to domestic travel.)
_____ As a Roosevelt University (“Roosevelt”) student participating or wanting to participate in travel, in a country or
part of a country for which the U. S. State Department has issued a Travel Warning (“Travel Warning”), I acknowledge
that (1) Roosevelt University will not operate, sponsor, fund, supervise, or direct travel to such locations and (2)
Roosevelt University will not grant financial aid or academic credit for programs in such locations.
_____ I agree that I have carefully identified, reviewed and considered the risks of travel to my destination(s). I have
read the most recent relevant U.S. State Department Travel Advisories available as well as the Roosevelt University-
Sponsored Student Travel Policy.
_____ I acknowledge that Roosevelt University will suspend all programs in a country or any portion thereof, for which
a Travel Warning is in effect, even if I am currently traveling in or planning to travel in that country.
_____ I understand that conditions in my travel destination area(s) may change rapidly, and I will stay informed of
current events on a frequent basis by obtaining updated security and health information from and registering with the
nearest U.S. Embassy or Consulate General (see State Department Travel Warning web site for contacts), and by
obtaining such information from the Department of State website. I also will enroll with the U.S. Consulate nearest my
destination(s). If I am not a U.S. citizen, I will register with my home countrys Embassy or Consulate and get updated
information from the U.S. and my home country’s Embassies or Consulates and the Department of State website.
_____ I further agree that if my travel destination area(s) come(s) under a Travel Warning, I will immediately and as
soon as possible depart such area. If I choose to stay in such area, I understand that Roosevelt University will not support
my travel.
_____ I understand that I am not required to travel, and that Roosevelt University urges me not to travel to my
destination(s) if a Travel Warning is in effect for such destination(s) or any portion thereof.
_____ I hereby acknowledge that I am participating voluntarily in the travel described above. I also acknowledge that my
participation in this travel may expose me to significant risks, especially if a Travel Warning is in effect for my
destination(s). Such risks may include, but not be limited to, terrorism, war, serious bodily injury or death, property
damage, and other risks that may not be foreseeable. I understand that Roosevelt University is not responsible for my
safety, and that I assume full responsibility for all risks associated with my travel.
_____ I affirm that I have health insurance that will remain in effect and cover any injuries or other health problems
sustained during my travel. I have submitted proof of health insurance to the Office of International Programs.
_____ I hereby acknowledge that I have discussed my travel with at least one of my parents or my legal guardian who
has also read and signed this form as indicated below.
Parent/Guardian Signature
Parent/Guardian Name: ________________________
Signature: ___________________________________
Date: _______________________________________
Student Signature
Student Name: ______________________________
Signature: __________________________________
Date: ______________________________________
Parent or Guardian must sign if Student is under 18 years old.
If a parent/guardian completes and signs this form because the participant is a minor or is otherwise not
authorized to enter into a contract, it is understood and agreed that the parent/guardian is making all
certifications and authorizations in the place of the participant, and the parent/guardian’s signature hereto shall
bind both the participant and the parent/guardian.
I, _____, certify that all responses made on this health and medical authorization form are true and accurate,
and I will notify [appropriate office or administrator] of any relevant changes in my health that may occur
before departure.
I acknowledge and agree that Roosevelt personnel shall not be responsible for holding, keeping track of, or
administering any medications, whether prescription or over-the-counter, during this university- sponsored
student travel, and that such obligations shall be solely my responsibility.
In the event of my illness or injury during the university-sponsored student travel, I hereby authorize
Roosevelt personnel to take me to the nearest hospital or emergency care facility. In such instances, Roosevelt
or emergency personnel should attempt to contact:
Emergency Contact 1 Emergency Contact 2
Emergency Contact Name: _________________ Emergency Contact Name: _________________
Relation to Student: _______________________ Relation to Student: _______________________
Emergency Contact Number: _______________ Emergency Contact Number: ________________
I further authorize Roosevelt or emergency personnel to contact my primary care physician in the event of an
Primary Care Physician Contact 1
Doctor Name: _______________________
Doctor Contact Number: _______________
I acknowledge that any emergency and/or medical expenses incurred are my responsibility, not Roosevelt’s,
while on such travel. Regardless of my insurance coverage, I hereby agree to assume sole responsibility for
any and all expenses incurred as a result of my emergency and/or medical care.
Participant or Parent Name: __________________ Date: ____________
Participant or Parent Signature: _______________
PLEASE RETURN COMPLETED FORMS TO: Designated travel/event program coordinator