Global Field Course Syllabus

Global field course Syllabus

Dear Student,

Below, in the order of which you must complete them, are the necessary forms and tasks required by ECSU for a student to participate in a faculty-led Global Field Course. Some of the forms require the signature of a Professor, Department Head, Director, or medical doctor. This guide should be used as a reference to assist in the understanding of forms and purpose behind signatures.

Please Note:Additional forms not listed below may be required of you from your host program. All forms must be blue/black ink and in clear hand writing.

Commitment Form:

This form is required if you intend to participate in a Global Field Course at Eastern Connecticut State University. Students participating must sign and submit this form to Carlos Corona in the Continuing Studies and Enhanced Learning/Study Abroad Office to be able to attend the trip.

Judicial Form:

This form should be taken by the student to Angelo Simoni in the Judicial Office located in the Wood Support Services Building room 210, 860-465-0063. The student will completeONLY the top portion of the front page and sign the back page. The judicial office or designee is required to fill out the rest of the sheet.

Student Application:

This form is required to be filled out and signed by the student who is participating in a Global Field Course. By filling out this form, you waive liability while participating in your Global Field Course, provide up to date and accurate health information and agree to allow Eastern’s Study Abroad Office to share information regarding your GFC program with individuals you have indicated. It is important to note that this form must be notarized and completed in blue/black ink only! No pencil applications will be accepted.(Notaries on campus include:Sonya Alicea, Wood Support Services Room 241; Susan Kennedy, Gelsi-Young Hall Room 341, Darren Nosal, Gelsi-Young Hall Room 338; George Whiting, Gelsi-Young Hall Room 324; or Donna Snell Gelsi-Young Hall Room 128D).

ECSU Student Medical History Form for Study Abroad Programs:

This form states that the student authorizes the release of information from their medical history upon the request of Eastern Connecticut State University, to its administrative centers and to cooperating or affiliated foreign institutions. The student’s signature certifies that the information on the form is true and takes responsibility for notifying ECSU thereafter of any relevant health changes prior to the start of their program. It also releases and forever discharges ECSU, its officers, agents, and employees from all claims, rights, demands, actions, obligations and causes of action of any and every kind. This form should be given to your doctor, signed by the student, and then faxed back to the Study Abroad Office (860) 465 – 5363 or Continuing Studies and Enhanced Learning Office (860)-465-0062, or returned to the study abroad office in a sealed envelope with the physician’s signature over the seal. NO EXCEPTIONS.

Statement of Fitness Declaration:

This form states that the student is medically fit and able to travel to the host country and participate in ECSU’s International Study Abroad Program. This form should be given to your doctor and then faxed back to the Study Abroad Office at (860) 465 – 5363 orContinuing Studies and Enhanced Learning Office (860)-465-0062,or returned to the study abroad office in a sealed envelope with the physician’s signature over the seal. NO EXCEPTIONS. The doctor will have read and reviewed the Center for Disease Control’s health and safety information related to the study abroad destination, finding no information that would prevent the patient’s participation, enclose any pertinent information concerning the patient’s health condition that could aid the Study Abroad Director in safeguarding the health of the patient should a medical situation arise and prescribe medication that is both legal and readily available in the host country.

Statement of Responsibility, Release, Indemnification, and Authorization:

This form contains important information pertaining to international health coverage, ECSU liability, a student’s legal rights,financial responsibilities, and authorization in case of a medical or legal emergency while traveling abroad. In signing it, a student is giving up substantial legal rights they might otherwise have and is doing so knowingly and voluntarily in compliance with the laws of the State of Connecticut. The first line should have the participant’s printed name and the following paragraphs should each be initialed in the provided space. It is important that you read this document over carefully and understand the entirety of its content. You must schedule a meeting with Dr. Petoskey or Designee (can be professor of the course), who will witness you signing the document. DO NOT sign it without him/her witnessing your signature, or the form will be VOID.

Guidelines for Student Rights & Responsibilities & Judicial Procedures Agreement and Release:

Included in this document is the University’s Definition of Misconduct. By signing the document, the student warrants that he/she is eighteen (18) years of age or older, has the authority to execute this agreement, and is not under guardianship, conservatorship or other legal authorities. The student also acknowledges that he/she has carefully read this agreement and understands the potential incident to engaging in this activity, is fully aware of the legal consequences of this Agreement, understands that he/she is releasing and waving certain rights, and assumes the risk of injury and damage from participation in the program.

Release of Liability and User Indemnity Agreement for Extra Curricular Travel During a Global Field Course:

This form states that with lawful consideration for having been permitted to depart the scheduled program early, (to pursue personal, non-academic travel activity) the student is releasing ECSU from any liability involving injury or death caused by or resulting from continued extracurricular travel activity.This form must be signed by student and faculty, or the form will be VOID.

Proof of Domestic Insurance Coverage:

ECSU requires that a student show proof of Domestic Insurance Coverage. This proof can be in the form of an insurance bill, an insurance card, a notarized letter from the insurance company, or other document; so long as it clearly states the company name, type of insurance and effective dates of coverage. You should also check with your insurance to make sure you are covered abroad.

On-Call Aetna Insurance:

ECSU now mandates each student to purchase On-Call student insurance through Aetna. All full-time students have access to the On-Call International ID Card at the following site: ( so they do not need to continue with the steps. All non-full-time students must click on the link, search Eastern Connecticut State University,Click on “Members services” on the left hand side of the welcome page, this will open up additional choices below, click on “Travel Assistance”. It gives the option to click “On Call International ID card” at the bottom of the page. Click on this and a new window opens with the ID card that can be printed, please submit a copy to the Study Abroad Office. It is recommended to call the number on the ID Card to verify your access to On-Call.

Color Copy of Valid Passport:

Students MUST make 2color copies of their passport. No copy, except a Color copy of the passport identification page, will be accepted. NO EXCEPTIONS. Students can obtain a colored copy of their passport by printing it on a colored copier or scanning the passport and printing it on a colored printer. At Staples, located on 82 Storrs Rd, Mansfield, CT (860-423-3143), there is a self-service copier located in the front of the store where you can copy your passport for cheap (Web 410 also offers students to print in color). A BLACK AND WHITE COPY OF YOUR PASSPORT WILL NOT BE ACCEPTED! Do not email copies! Only hard copies will be accepted.

Rev 3/26/2016