SVCC AUTHORIZATION AND ASSUMPTION OF THE RISK
COLLEGE STUDY ABROAD PROGRAM
To be submitted in duplicate to the Office of the Dean of Instruction. That office will forward one copy to the instructor or institution concerned. This form must be filed 15 days prior to the scheduled departure for the off-campus location(s).
Name ________________________________ Social Security No. ______________________
Course No. ____________ Title _________________________________________________
Contact Telephone Number While Traveling: ________________________________________
(Please check with your cell phone provider several weeks prior to departure to ensure that telephone service will be provided to you while traveling. If not, it is your responsibility to obtain and provide the Program director with a contact number that will work during the Program before departure.)
Emergency Contact Person and Number in the United States: ____________________________
1. In consideration for being permitted to participate in the Southside Virginia Community College's (the “College's”) Study Abroad Program (“the Program”) and in order to afford an enlarged educational experience to the above-named participant, the undersigned and his/her parents or guardians, if participant is under the legal age of 18, agrees to the following:
a. I understand that, although the College has made reasonable efforts to assure my safety while participating in the Program, that there are unavoidable risks involved in travel overseas. I therefore understand that there is no guarantee that this Program is free of risk of personal injury, property damage or loss. I agree to assume the risk for any injury, such as and including sickness or death to me, or damage or loss to my property, which may occur as a result of my, or arise out of my, participation in this Program due to airline and ground travel, and general risks associated with visiting a foreign country with different laws, regulations, medical care and possibly including exposure to different diseases, other health risks, and a different language or languages. I understand that the only exception to the preceding sentence is if injury, loss or damage is due to the negligence of the employees or agents of the College.
b. I further agree to indemnify the College and its trustees, officers, instructors, employees, agents, successors and assigns for any and all obligations, liabilities, claims, demands, costs and expenses, including attorneys’ fees, arising out of, or in any way connected with, any activities associated with the Program experiences participated in as part of the above course, except where such are due to the negligence of the employees or agents of the College.
c. In subscribing to this, I/We understand that enrollment in the above course will involve temporary residence at ______________________ and/or a period of travel from __________, 20___ until ___________, 20____.
d. I agree that, should there be any dispute concerning my participation in the Program that would require the adjudication of a court of law, such adjudication will occur in the courts of, and be determined by the laws of, the Commonwealth of Virginia.
2. I represent that my agreement to the provisions herein is wholly voluntary, and further understand that, prior to signing this agreement, I have the right to consult with the adviser, counselor or attorney of my choice.
Health Insurance
I/We further acknowledge that the participating student is protected for illnesses and injuries while traveling outside the U.S. by health and accident insurance as indicated below:
Company Name _________________________________________________
Address ________________________________________________________
Policy or Contract Number _________________________________________
Medical Service
I/We further authorize medical service and appropriate treatment for any illness of the participant while involved in this Program, including necessary surgical treatment.
IN WITNESS WHEREOF, the undersigned execute this agreement of authorization and assumption of the risks involved, this ____________ day of____________, 20____.
_________________________________________
Student Participant Signature
__________________________________________
Parent/Guardian Signature (if applicable)
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