Loyolauniversitychicagostritchschool of Medicine

LoyolaUniversityChicagoStritchSchool of Medicine

INTERNATIONAL ELECTIVES

Acknowledgement of Risks and Release of Responsibility

Name

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Dates of Elective Elective Clinical Location

Loyola University Chicago Stritch School of Medicine (LUC) offers students the opportunity to enroll in international clinical electives. Certain potential risks to personal health and safety are associated with international travel and residence in a foreign country. You should not participate in a clinical elective abroad unless you understand and are willing to accept the associated risks. LUC cannot guarantee the health and safety of participants in a clinical elective overseas or eliminate all risks from elective locations.

• I understand that there are certain risks associated with international travel and residence in a foreign country and that LUC and its staff cannot control these risks.

• I understand that these risks may include exposure to potential serious health and safety hazards such as transportation accidents, storms, floods, earthquakes and other natural disasters, infectious diseases, inadequate medical care, remote access to medical care, inadequate standards of sanitation, political instability, armed insurrections and terrorist activities.

• I understand that LUC is not in a position to guarantee my personal health or safety during my participation in this elective rotation abroad.

• I understand and specifically acknowledge that I have been apprised of these risks of travel issued by the U.S. Department of State as identified in the Travel Warnings and Consular Information Sheets ( and the Worldwide Caution Public Announcement (

• I understand, acknowledge, and agree that I have voluntarily chosen to participate in this elective rotation overseas, knowing the identified risks of travel and knowing further that I am solely responsible for my own safety and care during my travel to and from the site of my elective, as well as my residence during the time of my elective rotation.

• I understand that due to possible interruption in air travel, I may be delayed in returning to the Chicagoland area to resume my regular coursework at LUC.

• I understand and agree to abide by any applicable rules and regulations of the clinical elective and the laws of the countries in which I will be present or travel through while participating in this elective.

• I understand and hereby acknowledge that I assume all risks incurred by my participation in this elective rotation abroad.

• In consideration of being allowed to participate in this elective rotation overseas, and in full recognition and appreciation of the inherent dangers, I hereby agree to release, indemnify and hold harmless LUC, its Board of Trustees, subsidiaries and affiliates, their officers, agents, faculty and employees, from any and all claims, suits, damages and expenses for any injury, loss, damage, accident, inconvenience or expense, arising out of or in any way connected with my participation in this elective rotation overseas including, but not limited to, the items outlined above.

• I am over the age of 18 years and state that I have read, understand, and intend to be bound by the foregoing, and further sate that I am participating in this elective rotation of my own free will.

Student SignatureDate