Statement of Responsibility and Release of Claims Form
Statement of Responsibility and Release of Claims Form
Statement of Responsibility and Release of Claims Form
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STATEMENT OF RESPONSIBILITY AND RELEASE OF CLAIMS<br />
REGARDING INTERNATIONAL PROGRAMS<br />
I am duly enrolled in the Education Abroad Program <strong>of</strong>fered by The University <strong>of</strong> Akron's<br />
_______________________________________________________________________________________<br />
(department or college)<br />
through the _____________________________________________________________________________<br />
(name <strong>of</strong> program)<br />
in_____________________________________________________________________________________<br />
(country or countries)<br />
during _______________________________________, __________________________.<br />
(term)<br />
Special Conditions: I underst<strong>and</strong> that this Program will require my traveling outside <strong>of</strong> the United States <strong>and</strong> that I may<br />
face special conditions abroad. To the extent that I have had any questions or concerns regarding conditions or risks <strong>of</strong><br />
the Program, I have had the opportunity to discuss these issues with the group leader(s).<br />
Behavioral Responsibilities: I am aware <strong>of</strong> the expected behavioral responsibility while participating in this program.<br />
As a guest in a foreign country, there are certain behaviors which will be unacceptable <strong>and</strong> could lead to possible<br />
disruption <strong>of</strong> my program. I assure the University that I shall conduct myself in an appropriate manner at all times. Such<br />
behavior shall include moments when in the company <strong>of</strong> other program members <strong>and</strong> moments when I may be<br />
physically separated from other program members or the group leader(s). I underst<strong>and</strong> that I will be personally<br />
responsible for my day-to-day activities <strong>and</strong> for ensuring my health <strong>and</strong> safety during my trip abroad.<br />
I underst<strong>and</strong> that if I violate rules <strong>and</strong> guidelines for the Program, or other applicable University rules while participating<br />
in the Program, that I may be subject to discipline in accordance with those rules. I further underst<strong>and</strong> that The<br />
University <strong>of</strong> Akron reserves the right to terminate my participation in the Program, if I violate these rules, <strong>and</strong> to return<br />
me to the United States without a refund <strong>of</strong> fees paid; <strong>and</strong>, The University <strong>of</strong> Akron will not pay any fee incurred in my<br />
return to the United States.<br />
Academic <strong>Responsibility</strong>: I acknowledge <strong>and</strong> underst<strong>and</strong> that I am responsible for maintaining a course <strong>of</strong> study while<br />
abroad. I guarantee that I will attend all classes, take all examinations <strong>and</strong> do all assigned work.<br />
Legal Problems: I acknowledge <strong>and</strong> underst<strong>and</strong> that should I fall into legal problems with any foreign nationals or<br />
government jurisdictions, that I will attend to the matter personally with my own personal funds. The laws <strong>of</strong> many<br />
foreign countries do not provide for due process <strong>and</strong> individual rights to the same extent as the laws <strong>of</strong> the United States.<br />
The University cannot <strong>of</strong>ficially represent me or my legal interests, nor can the University assume any direct<br />
responsibility for the actions <strong>of</strong> a foreign government.<br />
(over)<br />
(year)<br />
Office <strong>of</strong> the Vice President for Student Affairs<br />
Office <strong>of</strong> International Programs<br />
The Polsky Building 483<br />
Akron, OH 44325-3101 USA<br />
(330) 972-6349 ● (330) 972-8604 Fax<br />
The University <strong>of</strong> Akron is an Equal Education <strong>and</strong> Employment Institution
Travel: I underst<strong>and</strong> that I will be responsible for obtaining my own passport, health certificate <strong>and</strong> other necessary<br />
travel documents. I acknowledge <strong>and</strong> underst<strong>and</strong> that in the event that I become detached from the group, fail to meet a<br />
departure bus or train, or become sick or injured, I will bear all responsibility to seek out, contact, <strong>and</strong> reach the group at<br />
its next available destination; <strong>and</strong>, I underst<strong>and</strong> that I shall bear all costs attendant to contacting <strong>and</strong> reaching the program<br />
site.<br />
The University <strong>of</strong> Akron cannot assure that travel arrangements will be without certain disruption. Transportation may<br />
not be as reliable or subject to the same safety st<strong>and</strong>ards applicable to public carriers in the United States. Accordingly, I<br />
acknowledge <strong>and</strong> agree to accept all responsibility for loss or additional expenses due to delays or other changes in the<br />
means <strong>of</strong> transportation, other services, sickness, weather, strikes, or other unforeseen causes.<br />
I acknowledge <strong>and</strong> underst<strong>and</strong> that The University <strong>of</strong> Akron assumes no liability whatsoever for any loss, damage,<br />
destruction, theft or the like to my luggage or personal belongings. I also acknowledge that I have retained adequate<br />
insurance or have sufficient funds to replace such belongings <strong>and</strong> will hold the University harmless therefrom.<br />
Medical <strong>Responsibility</strong>: I am aware that there are certain risks inherent in international travel <strong>and</strong> that The University <strong>of</strong><br />
Akron, as a State <strong>of</strong> Ohio educational institution, cannot assume responsibility for all or certain <strong>of</strong> my activities. Health<br />
care, medicines <strong>and</strong> related services may not be as readily available or <strong>of</strong> a quality comparable to those in the United<br />
States. I am aware <strong>of</strong> my personal medical needs <strong>and</strong> hereby assure the University that I have consulted with a medical<br />
doctor, as I have deemed necessary with regard to any personal needs. Further, I am aware that the University cannot be<br />
responsible for attending to any <strong>of</strong> my medical needs.<br />
I am aware that, should I be required to be hospitalized while in a foreign country or in the United States during this<br />
Program, the University cannot <strong>and</strong> does not assume any legal responsibility for payment <strong>of</strong> such costs; rather, I hereby<br />
assure the University that I have assumed all risk <strong>and</strong> responsibility therefor <strong>and</strong> that I have adequate insurance coverage<br />
to meet any <strong>and</strong> all needs for payment <strong>of</strong> hospital or other medical costs during this program.<br />
To the extent that I require special accommodation as part <strong>of</strong> the Program, I have discussed those needs with the group<br />
leader prior to committing to the Program.<br />
Change in the Program: I acknowledge <strong>and</strong> underst<strong>and</strong> that no refunds for program fees will be made after departure.<br />
Certain unrecoverable costs may also be assessed to me if cancellation is necessary before departure. I acknowledge the<br />
right <strong>of</strong> the University to withdraw, change, alter, delete or modify the itinerary <strong>and</strong>/or academic program as deemed<br />
necessary by the University.<br />
Authorization: I authorize the use <strong>of</strong> my name, likeness <strong>and</strong> program evaluations for promotional purposes for the<br />
Education Abroad Program at The University <strong>of</strong> Akron.<br />
In consideration for the opportunity to participate in the Program, I hereby release <strong>and</strong> forever discharge The University<br />
<strong>of</strong> Akron, its Board <strong>of</strong> Trustees, <strong>of</strong>ficers, employees <strong>and</strong> agents from any <strong>and</strong> all claims for injury, damage, or loss <strong>of</strong> any<br />
kind, which may arise out <strong>of</strong> my participation, other than those claims directly attributable to the negligent acts or<br />
omissions <strong>of</strong> The University <strong>of</strong> Akron.<br />
This agreement shall be construed under <strong>and</strong> in accordance with the laws <strong>of</strong> the State <strong>of</strong> Ohio.<br />
I certify that I have fully read this release <strong>and</strong> that I underst<strong>and</strong> its terms <strong>and</strong> conditions <strong>and</strong> agree to be bound by them. I<br />
also certify that I am over the age <strong>of</strong> eighteen (18) <strong>and</strong> have executed this agreement <strong>of</strong> my own free will.<br />
Witness:<br />
___________________________________________<br />
Print Name<br />
___________________________________________<br />
Signature <strong>of</strong> Witness<br />
Revised 3-1-11<br />
Participant:<br />
____________________________________________<br />
Print Name<br />
____________________________________________<br />
Signature <strong>of</strong> Participant<br />
____________________________________________<br />
Date