Seattle College District

LIABILITY RELEASE AND AUTHORIZATION FORM

(please sign and return only pages 1-2)

Program Name: GLOBAL IMPACT: Ghana

Program Location: Ghana-Keta

Program Sponsor:

Program begins:______and ends:______

I, ______, have agreed to participate in an International Program sponsored by the Seattle Colleges ("the College"), in collaboration with international host organizations, in Ghana from ______to ______("the Program"). I understand and hereby acknowledge that my participation in the Program is wholly voluntary. In consideration of being allowed to participate in the Program, I hereby agree as follows:

1) I hereby represent and warrant that I am and will be covered throughout the Program by a policy of comprehensive health and accident insurance which provides coverage for injuries and illnesses I sustain or experience overseas, and, more specifically, in the country in which I will be living and/or traveling while on the Program in Ghana. My insurance policy supplied by the ProWorld Ghana provider will also cover medical evacuation and repatriation of remains. By my signature below, I certify that my health insurance policy will adequately cover me while outside the United States; and, I absolve the College, its employees, agents, and tour leaders of all responsibility and liability for any injuries (including death), illnesses, claims, damages, charges, bills and/or expenses I may incur while I am abroad. I agree to report to the College any physical or mental condition I have which may require special medical attention or accommodation during the Program at least thirty (30) days prior to departure.

2) I understand that the College reserves the right to make changes to the Program itinerary at any time and for any reason, with or without notice, and the College shall not be liable for any loss whatsoever to me by reason of any such cancellation or change. The College is not responsible for penalties assessed by air carriers that may result due to operational and/or itinerary changes, regardless of whether the College makes a flight arrangement. Any additional expense resulting from the above will be paid by me. The College reserves the right to substitute hotels or accommodations or housing of a similar category at any time. Specific room and housing assignments are within the sole discretion of the College.

3) I understand and acknowledge that the College assumes no responsibility or liability, in whole or in part, for any delays, delayed or changed departure or arrival times, fare changes, dishonors of hotel, airline or vehicle rental reservations, missed carrier connections, sickness, disease, injuries (including death), losses, damages, weather, strikes, acts of God, circumstances beyond the control of the College, force majeure, war, quarantine, civil unrest, public health risks, criminal activity, terrorism, expense, accident, injuries, damage to property, bankruptcies of airlines or other service providers, inconveniences, cessation of operations, mechanical defects, failure or negligence of any nature howsoever caused in connection with any accommodations, restaurant, transportation, or other service or for any substitution of hotels or of common carriers beyond the College's control, with or without notice, or for any additional expense occasioned by any of the foregoing. If due to weather, flight schedules, or other uncontrollable factors I am required to spend additional nights, the College will not be responsible for my hotel, transfers, meal costs, or other expenses. My baggage and personal property are transported at my risk entirely. The College reserves the right to decline to accept or retain me in the Program at any time should my actions or general behavior impede the operation of the Program or the rights or welfare of any person. Similarly, if my conduct violates any policy or procedure of the College, I understand that I may be required to leave the Program in the sole discretion of the College's employees, agents, and representatives, and I may be referred to the appropriate College officials for further disciplinary or other

action. In such an event, no refund will be made for any unused portion of the Program. The right is reserved by the College, in its sole discretion, to cancel the Program or any aspect thereof prior to departure; and, in the College's sole discretion to cancel the Program or any aspect thereof after departure, requiring that all participants return to the United States if the College determines or believes that any person is or will be in danger if the Program or any aspect thereof is continued.

4) I understand and hereby acknowledge that I have received and reviewed the U.S. Consular Information, as well as the Centers for Disease Control information, on travel to, in and around Ghana that I am aware of and understand the risks and dangers of travel to, in, and around Ghana, including but not limited to the dangers to my own health and personal safety posed by the use of public transportation in Ghana, and by civil unrest, political instability, terrorism, crime, violence, and disease in Ghana. I hereby assume, knowingly and voluntarily, each of these risks and all of the other risks that could arise out of or occur during my travel to, from, in, or around Ghana.

5) I hereby acknowledge that I have read, understand and will abide by each of the terms and conditions of this Agreement.

______

Participant’s name (print or type) Participant’s signature Date (mo/day/yr)

Participant is advised to undergo a complete health evaluation and must select one of the options below to confirm preparations:

 I currently have, or will acquire before departure, adequate major medical insurance which includes international/overseas coverage, medical evacuation and repatriation of remains. Either I or my institution’s study abroad program will provide a copy of this policy prior to paying final program fees.

Name of Insurance:______Policy #______

 I will purchase the INEXT insurance policy offered through the Seattle Colleges ($32 fee as of 2016 for a year’s coverage while overseas.)

Participant’s signature:______Date:______


Please keep the following pages:

Preparing for Your Trip to Ghana

Before visiting Ghana, you may need to get the following vaccinations and medications for vaccine-preventable diseases and other diseases you might be at risk for at your destination: (Note: Your doctor or health-care provider will determine what you will need, depending on factors such as your health and immunization history, areas of the country you will be visiting, and planned activities.)

To have the most benefit, see a health-care provider at least 4–6 weeks before your trip to allow time for your vaccines to take effect and to start taking medicine to prevent malaria, if you need it.

Even if you have less than 4 weeks before you leave, you should still see a health-care provider for needed vaccines, anti-malaria drugs and other medications and information about how to protect yourself from illness and injury while traveling.

CDC recommends that you see a health-care provider who specializes in Travel Medicine. Find a travel medicine clinic near you. If you have a medical condition, you should also share your travel plans with any doctors you are currently seeing for other medical reasons.

If your travel plans will take you to more than one country during a single trip, be sure to let your health-care provider know so that you can receive the appropriate vaccinations and information for all of your destinations. Long-term travelers, such as those who plan to work or study abroad, may also need additional vaccinations as required by their employer or school.

Be sure your routine vaccinations are up-to-date. Check the links below to see which vaccinations adults and children should get.

Routine vaccines, as they are often called, such as for influenza, chickenpox (or varicella), polio, measles/mumps/rubella (MMR), and diphtheria/pertussis/tetanus (DPT) are given at all stages of life; see the childhood and adolescent immunization schedule and routine adult immunization schedule.

Routine vaccines are recommended even if you do not travel. Although childhood diseases, such as measles, rarely occur in the United States, they are still common in many parts of the world. A traveler who is not vaccinated would be at risk for infection.

Vaccine-Preventable Diseases

Vaccine recommendations are based on the best available risk information. Please note that the level of risk for vaccine-preventable diseases can change at any time.

Vaccination or Disease / Recommendations or Requirements for Vaccine-Preventable Diseases /
Routine / Recommended if you are not up-to-date with routine shots, such as measles/mumps/rubella (MMR) vaccine, diphtheria/pertussis/tetanus (DPT) vaccine, poliovirus vaccine, etc. /
Hepatitis A or immune globulin (IG) / Recommended for all unvaccinated people traveling to or working in countries with an intermediate or high level of hepatitis A virus infection (see map) where exposure might occur through food or water. Cases of travel-related hepatitis A can also occur in travelers to developing countries with "standard" tourist itineraries, accommodations, and food consumption behaviors. /
Hepatitis B / Recommended for all unvaccinated persons traveling to or working in countries with intermediate to high levels of endemic HBV transmission (see map), especially those who might be exposed to blood or body fluids, have sexual contact with the local population, or be exposed through medical treatment (e.g., for an accident). /
Typhoid / Recommended for all unvaccinated people traveling to or working in West Africa, especially if staying with friends or relatives or visiting smaller cities, villages, or rural areas where exposure might occur through food or water. /
Yellow Fever / Requirements: Required upon arrival for all travelers ≥9 months of age.
Recommendations: Recommended for all travelers ≥9 months of age.
Vaccination should be given 10 days before travel and at 10-year intervals if there is on-going risk. Find an authorized U.S. yellow fever vaccination clinic. /
Meningococcal (meningitis) / Recommended if you plan to visit countries that experience epidemics of meningococcal disease during December through June (see map). /
Rabies / Recommended for travelers spending a lot of time outdoors, especially in rural areas, involved in activities such as bicycling, camping, or hiking. Also recommended for travelers with significant occupational risks (such as veterinarians), for long-term travelers and expatriates living in areas with a significant risk of exposure, and for travelers involved in any activities that might bring them into direct contact with bats, carnivores, and other mammals. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites. /

Malaria

Areas of Ghana with Malaria: All (more information)

If you will be visiting an area of Ghana with malaria, you will need to discuss with your doctor the best ways for you to avoid getting sick with malaria. Ways to prevent malaria include the following:

·  Taking a prescription antimalarial drug

·  Using insect repellent and wearing long pants and sleeves to prevent mosquito bites

·  Sleeping in air-conditioned or well-screened rooms or using bednets

All of the following antimalarial drugs are equal options for preventing malaria in Ghana: Atovaquone-proguanil, doxycycline, or mefloquine. For detailed information about each of these drugs, see Table 3-11: Drugs used in the prophylaxis of malaria. For information that can help you and your doctor decide which of these drugs would be best for you, please see Choosing a Drug to Prevent Malaria.

Note: Chloroquine is NOT an effective antimalarial drug in Ghana and should not be taken to prevent malaria in this region.

To find out more information on malaria throughout the world, you can use the interactive CDC malaria map. You can search or browse countries, cities, and place names for more specific malaria risk information and the recommended prevention medicines for that area.


Malaria Contact for Health-Care Providers
For assistance with the diagnosis or management of suspected cases of malaria, call the CDC Malaria Hotline: 770-488-7788 or toll-free 1-855-856-4713 (M-F, 9 am-5 pm, Eastern time). For clinicians needing emergency consultation after hours, call 770-488-7100 and ask to speak with a CDC Malaria Branch clinician.

A Special Note about Antimalarial Drugs

You should purchase your antimalarial drugs before travel. Drugs purchased overseas may not be manufactured according to United States standards and may not be effective. They also may be dangerous, contain counterfeit medications or contaminants, or be combinations of drugs that are not safe to use.

Halofantrine (marketed as Halfan) is widely used overseas to treat malaria. CDC recommends that you do NOT use halofantrine because of serious heart-related side effects, including deaths. You should avoid using antimalarial drugs that are not recommended unless you have been diagnosed with life-threatening malaria and no other options are immediately available.

For detailed information about these antimalarial drugs, see Choosing a Drug to Prevent Malaria.

More Information About Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health-care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites (see below).

Travelers to malaria risk-areas in Ghana, including infants, children, and former residents of Ghana, should take one of the antimalarial drugs listed in the box above.

Symptoms

Malaria symptoms may include

·  fever

·  chills

·  sweats

·  headache

·  body aches

·  nausea and vomiting

·  fatigue

Malaria symptoms will occur at least 7 to 9 days after being bitten by an infected mosquito. Fever in the first week of travel in a malaria-risk area is unlikely to be malaria; however, you should see a doctor right away if you develop a fever during your trip.

Malaria may cause anemia and jaundice. Malaria infections with Plasmodium falciparum, if not promptly treated, may cause kidney failure, coma, and death. Despite using the protective measures outlined above, travelers may still develop malaria up to a year after returning from a malarious area. You should see a doctor immediately if you develop a fever anytime during the year following your return and tell the physician of your travel.

Items to Bring With You

Medicines you may need:

·  The prescription medicines you take every day. Make sure you have enough to last during your trip. Keep them in their original prescription bottles and always in your carry-on luggage. Be sure to follow security guidelines, if the medicines are liquids.