Release, Assumption of Risk, and Covenant Not to Sue For

Emory University

GoizuetaBusinessSchool

Release, Assumption of Risk, and Covenant Not to Sue for

Participation inSpring2012 Mid-SemesterModule

in

______(location of travel)

In connection with theSpring2012Mid-Semester Module, Emory University has made arrangements that will permit me to participatein a program in ______(location of travel)from ______to ______. I realize that this activity involves a level of risk that is greater than an average off-campus activity in the United States. I also understand that participation in this program is my choice. I am aware that during the Mid-Semester Moduleactivity in which I am participating– under the arrangements of Emory University and its agents, employees, officers and faculty – certain risks and dangers may occur, including, but not limited to, the hazards of traveling, accident or illness, malaria, the forces of nature, travel by air, train, automobile, or other conveyance, and the exposure to acts of terrorism or war.

I understand that EmoryUniversity does not warrant or guarantee in any respect the competency or mental or physical condition of any person associated with this activity, the physical condition of any facility or equipment used in connection with this activity, or the suitability of this activity for my participation. I understand that EmoryUniversity does not provide me with any insurance, whether health, accident, or otherwise, in connection with this activity and I state that I am aware that I’ve been advised to purchase an insurance policy. In addition Emory has advised me to seek anyvaccinations and medications for vaccine-preventable diseases and other diseases I might be at risk for at my destination based on a recommended by the CDC. I also understand that the risks involved in participation in this activity include damage, whether to person or property, injury, or death. Further, I am aware and understand that Emory cannot guarantee what assistance it can provide if I develop a legal problem in a foreign country.

In consideration of being permitted to participate in this activity, I voluntarily assume all risks associated with this activity.

I further agree that, in consideration of being permitted to participate in this activity, I hereby release, covenant not to sue and forever discharge Emory University and its trustees, officers, agents, employees, and students of any and from all claims, demands, rights and causes of action of whatever kind or nature including but not limited to negligence, arising from and by reason of any and all known and unknown, foreseen bodily and personal injuries, damage to property, and the consequences thereof, including death, resulting from any participation in or in any way connected with such activity.

I expressly agree that the terms of thisRelease, Assumption of Risk, and Covenant Not to Sue, shall be binding upon me and my heirs, executors and assigns, and all members of my family.

I expressly agree that this Release, Assumption of Risk, and Covenant Not To Sue shall be governed by and interpreted in accordance with the laws of the State of Georgia without regard to conflict of law principles. I intend this to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that,in the event that any clause or provision of this Release is held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release.

By signing this document, I hereby acknowledge that I have read the above carefully before signing, that I understand its terms, and that I agree to be bound by all the above as of the date of my signature below.

Participant Signature:______Date: ______

Print Name: ______

Attach a copy of your passport biographical information page to this form.

Please list any medical conditions that the trip coordinators should know:

I acknowledge thatI have been advised:

Apassport is required and must be valid for 6 months after travel date and must have blank pages.

A visa may be necessary for travel

Students not maintaining proper conduct as determined by the trip leader or Goizueta staff may be sent home at their own expense

To contact my health care provider to be sure my immunizations are up to date

A refund is not available if I cancel for any reason

To submit my personal and flight information on International SOS website and provide a copy to the MBA Program Office.

Participant Initials