STUDY ABROAD

SVCC AUTHORIZATION AND WAIVER

To be submitted in duplicate to the Office of Dean of Instruction.  That office will forward one copy to the instructor or institution concerned.  Authorization and waiver must be filed 90 days prior to the schedule departure for the off-campus location(s).

                  Student Name________________________

               Social Security No. ________________

A.              In order to afford an enlarged educational experience to the above student, the undersigned participant and his/her parents or guardians agree to and hereby release Southside Virginia Community College and its trustees, officers, instructors, employees, agents, successors and assigns from any and all responsibility for and do hereby indemnify each against and hold them harmless from all obligations, liabilities, claims, demands, costs and expenses, including attorneys’ fees, arising out of or in any way connected with any activities associated with off-campus experiences participated in as part of the above course or program.

                  In subscribing to this, the undersigned have full knowledge of the special risks which may be inherent in travel and residence in a foreign country or in other off-campus locations, and do, jointly and severally, for themselves and their estates, agree and consent not to bring legal action against Southside Virginia Community College or any of its trustees, officers, employees or agents, successors or assigns for or on any matter associated with the off-campus experience provided through this instructional program.  We understand that enrollment in the above course will involve temporary residence at _________________________and/or a period of travel from

                  ___________________, 20___ until _______________, 20__.

B.              Health Insurance

                  We further acknowledge that the participating student is protected while traveling outside the U.S. by health and accident insurance as indicated below:

                                                  Company Name ________________________________________

                                                     Address _________________________________________________________

                                                      Policy or Contract Number __________________________________________

C.              Medical Service

                  We further authorize medical service and appropriate treatment for any illness of the participating student while off-campus, including necessary surgical treatment.

                  IN WITNESS WHEREOF, the undersigned execute this agreement of authorization and waiver, this the ____________day of _________________, 20___.

                                                                                      ______________________________________________

                    Student Participant Signature

                                                                                      ______________________________________________

                   Parent(s) /Guardian(s) Signature