HANBAN CHINA SUMMER CAMP
PARENT/GUARDIAN STATEMENT, STUDENT STATEMENT,
MEDICAL INFORMATION, CONTRACT & WAIVER
PARENT/GUARDIAN STATEMENT
By signing this application, the Student, parent or guardian give my consent for______to participate in the “Chinese Bridge” US High Schools Students Summer Camp from July 17-August 1, 2014. The Student, parent or guardian also confirms that my son/daughter is in good health and very able to meet the physical demands of this three-week trip. If my son/daughter is selected to participate in the trip, and he/she accepts, the Student, parent or guardian will be responsible for paying all fees in full by the stated deadlines.
I also acknowledge and agree that the “Chinese Bridge” US High Schools Students Summer Camp is not a program of Wayne State University.
______
Parent/Guardian signature
STUDENT STATEMENT
I have answered all questions honestly, and to the best of my knowledge used original ideas in my short answer essay. If selected to participate in the Chinese Bridge for American Schools’ summer language camp from July 17-August 1, 2014, the Student, parent or guardian will do my best to represent my family, school, and country well.
______
Student signature
MEDICAL INFORMATION
Please answer the questions below. The information you provide will be kept in your private file in the office and will only be shared with those who must have access in case of an emergency. Your cooperation is sincerely appreciated.
1. Are you currently receiving medical treatment? Yes No
If yes, please explain
2. Are you currently receiving counseling or medication for any psychological or emotional
conditions? Yes No
If yes, please explain
3. Do you have any allergies or physical disabilities that may require medical assistance?
Yes No
If yes, please explain
4. Do you require any accommodation in order to travel or to otherwise participate in program activities?
Yes No
If yes, please explain
Participant / Parent / Guardian Signature ______Date ______
I verify that my child / the Student, parent or guardian is covered under a health insurance policy, which provides coverage to the destination, and will be in effect during the entire period of my off-campus travel.
PHOTOCOPY OF THIS COVERAGE MUST BE ATTACHED TO THIS DOCUMENT
(Insurance Card or Policy).
Health Insurance Provider: ______
Policy # Health Insurance Phone: ______
______
Participant Signature Date
______
Parent / Guardian Signature (if student is under 18) Date
Form: Contract and Release
Acknowledgement
I, ______, understand that:
While visiting a foreign country or countries, the student will be expected to maintain a standard of behavior and integrity that will reflect positively on the sponsoring organization, the student’s school, family, the student, Wayne State University and the United States of America.
The student and parent and guardian further understand and acknowledge that the student has a responsibility to obey the laws of the country being visited and to behave in a mature and appropriate manner. Guidance for such behavior can be found in the rules and regulations of the institution as outlined in the Wayne State University Student Code of Conduct (http://www.doso.wayne.edu/codeofconduct.pdf), as well as in the laws, regulations, and expectations enforced by host institution, country, government, and culture. The student and family agree to conform to these standards and understand that if the student fails to do so the student shall be subject to discipline up to and including being sent home with no refund as well as criminal penalties if applicable.
The student, parents and guardian agree that the student shall not engage in any illegal activity, nor will the student engage in activities not in compliance with the academic spirit of this trip or that are detrimental to the learning experience of others.
I understand that Wayne State University is not the sponsoring institution of this event and the University, its Board of Governors, officers, administrators, faculty and other employees are not responsible for any of the following:
1. The safety of participants or eliminating risk from the off-campus study environments.
2. Monitoring or controlling all the daily personal decisions, choices, and activities of individual participants.
3. Preventing participants from engaging in illegal, dangerous, or unwise activities.
4. Assuming responsibility for the actions of persons not employed or otherwise engaged by the program sponsor for events beyond the control of the sponsor and its subcontractors, or for situations which arise due to failure of a participant to disclose pertinent information. If the Student, parent or guardian am unable to attend the pre-departure orientation sponsored by the lead faculty member, I will make arrangements to obtain and absorb the information contained therein before departure.
______
Student Signature Date Parent’s Signature (if student is under 18) Date
LIABILITY RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE
THIS IS A RELEASE OF LEGAL RIGHTS.
READ AND BE CERTAIN YOU
UNDERSTAND IT BEFORE SIGNING.
______, (student name printed) (hereafter “the Student”) wishes to participate in an international study program in ______from ______until ______("the Program"). In consideration for being permitted to participate in the Program, I hereby agree and represent that:
The Student, parent or guardian desire for the Student to participate in the following international travel study program:
“Chinese Bridge” US High School Students Summer Camp to be held from July 17-August 1, 2014 and the Student, parent or guardian fully understand and appreciate the dangers, hazards and risks inherent in the Activity, in the transportation to and from the Activity, and in any independent research or activities undertake as a participant to the Activity, which could include serious or even fatal injuries and property damage.
1. The student shall have or shall secure health insurance to provide adequate coverage (including emergency evacuation and repatriation coverage) for any injuries or illnesses that I may sustain or experience while participating in the Program. By student, parent or guardian’s signature below the student, parent or guardian certifies that the Student has confirmed health care coverage adequate to cover the Student while outside the United States, and hereby releases the University, and its employees and agents from any responsibility or liability for any and all expenses incurred by the Student for injuries or illnesses (including death) that the Student may incur because of those injuries or illnesses.
2. The Student understands and agrees that, although the sponsoring institutions shall attempt to maintain the Program as described in its publications, it reserves the right to change the Program including, but not limited to, the curricula, instructors, itinerary, travel arrangements, or accommodations, at any time and for any reason, with or without notice, and that neither the sponsoring institutions, or its employees and agents, shall be responsible or liable for any expenses or losses sustained because of these changes.
3. The Student understands and agrees to comply with all applicable rules, regulations, laws and policies governing students in the Program. The student, parent and guardian understand and agree that the Program reserves the right to dismiss the Student from the Program at any time should Student’s actions or general behavior, in the sole discretion of the Program, be determined to constitute a danger to Student, others, or to the acceptability of the Program to its hosts, or if it is determined that the Student’s actions or general behavior impedes or obstructs the progress and objectives of the Program in any way.
4. The Student understands and agrees that that there are unavoidable risks in travel overseas, and the Student, parent and guardian hereby releases and promises not to sue the University, or its employees and agents, for any damages or injury (including death) caused by, deriving from, or associated with participation in the Program, except for such damages or injury as may be caused by the gross negligence of the employees or agents of the University.
5. The Student, parent and guardian also agree to indemnify and defend the University, its Board of Governors, agents and employees against any liability incurred by them as a result of the Student’s conduct
6. The Student also understands and agrees that the Student will have to rely upon medical facilities generally available in the locale where travelling. The University assumes no responsibility for such health matters.
7. The Student, parent and guardian acknowledge that they have consulted with a qualified medical doctor and that based on that consultation there are no physical or mental health-related reasons or problems which preclude or restrict participation in the program or which require any accommodation.
8. The Student, parent and guardian agree that, should any provision or aspect of this agreement be found to be unenforceable, that all remaining provisions of the agreement will remain in full force and effect.
9. The Student, parent and guardian represent that their agreement to the provisions herein is wholly voluntary, and further understand that, prior to signing this agreement, they have the right to consult with the adviser, counselor, or attorney of my choice.
10. The Student, parent and guardian agree that, should there be any dispute concerning the Program that would require the adjudication of a court of law, such adjudication will occur in the Michigan Court of Claims, and be determined by the laws of the State of Michigan.
11. The Student, parent and guardian agree that the University nor any of its agents shall not be liable or considered in default under this Agreement when the delay of performance, or non-performance, is caused by circumstances beyond its control and occurring without its fault, including failure of suppliers, subcontractors, and carriers, acts of civil or military authorities, national emergencies, fire, flood, acts of God, riot, natural and/or man-made disaster, civil disturbance, labor dispute, work stoppage/slowdown, insurrection, and war, provided the party invoking this paragraph provides reasonably prompt notice thereof to the other.
12. This agreement represents the complete agreement with the Program concerning the University's responsibility and liability for The Student’s, parent’s and guardian’s participation in the Program. This agreement and waiver supersedes any previous or contemporaneous understandings The Student, parent and guardian may have had with the University on this subject, whether written or oral. This agreement shall not be changed or amended in any way except in writing signed by University Provost and/or the Provost’s designated representative and myself (or legal guardian.)
13. The Student, parent and guardian represent that the Student is at least eighteen years of age or, if not, that parent or guardian as well the Student have signed below.
______
Student
Date: ______
______
Signature of parent or guardian (if required):
Date:
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