Customer will pick up the card: Mail card to customer: Yes To home address: To UF Campus address:

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1 170 HUB Stadium Road. PO Box Gainesville, FL Phone: Fax: MEDEX Emergency Assistance Program Enrollment Form Please complete and submit with payment to the address below: University of Florida International Center PO Box , 170 HUB, Gainesville, Florida, Phone: or Fax: Office use only: Application received by Amount Paid: $ Ck / Receipt #: Begin: End: Card issued: Yes No By: PLEASE PRINT CLEARLY: Customer will pick up the card: Mail card to customer:yes To home address: To UF Campus address: Personal information: Last Name: First: Middle initial: Gender: Male Female UF ID #: Date of birth: Address: Apt. #: City: State: Zip code: Work phone #: Home phone #: Foreign Site Contact (institution, organization, etc..): City: Country: Phone #: Fax #: contact abroad (may be host, personal, or other): Coverage period: Monthly Year Departure date: Return date: Department: Departmental Contact: Title: Campus Address: address: Phone #: 24hr #: EMERGENCY CONTACTS, in case of an emergency the following will be contacted: 1) Last name: First name: Relationship: Work phone #: Home Phone #: 2) Last name: First name: Relationship: Work phone #: Home Phone #:

2 170 HUB Stadium Road. PO Box Gainesville, FL Phone: Fax: Medex Rates* (Effective 8/1/09-7/31/10) one month increment $10.00 All enrollment expires 7/31/10 annual rate $60.00 All enrollment expires 7/31/10 *Note: Medex rates are based on a 30 day period. Make checks payable to University of Florida. The emergency assistance plan, for which you are applying, provides assistance related to physician referrals, medical evacuation, repatriation of remains and 24hr emergency contact service (via toll free or collect phone calls). Additional components of this plan require that you carry major medical insurance that is valid during your international travel. The emergency assistance plan provided through UFIC relies on existing major medical insurance for instances of hospitalization where prepayment may be required. Please note that HMO's and other similar insurance policies provide reduced and/or conditional services abroad, which may not adequately cover you. Faculty, staff and graduate students are required to ensure that they have adequate health insurance coverage while travelling Major Medical Health Insurance Information (ATTACH COPY OF INSURANCE CARD, OPTIONAL) Company Name (ex. State of Florida PPO, Blue Cross, etc..): Phone #: Insured name: Policy Number: Is this an: HMO, PPO, PPC, Other I am traveling on (check all that apply): University of Florida business, grant sponsored activity/research, as part of work required for graduate level degree program, other university related activity: By completing this application I authorize UFIC to enroll me in the emergency assistance plan for the dates indicated. I understand that this fee is non-refundable and that should I require any extensions I will notify the UFIC office prior the expiration date indicated above. By signing this application, I acknowledge receipt of the risk management Check List for Independent International Academic Work/Research and accept responsibility for reviewing the U.S. State Department Travel Advisory and Warnings prior to my departure. By signing this application, I certify that I have checked with my major medical insurance company and verified that my insurance covers me while traveling outside of the United States. Signature: Date: Revised July 09

3 Release, Indemnification, Waiver, and Hold Harmless Agreement In consideration for being allowed to participate in Independent International Academic Work/Research for the University of Florida, I hereby RELEASE and DISCHARGE the University of Florida, the Board of Regents, The State of Florida, their employees, agents and assigns (RELEASEES) from any and all liability, arising out of any loss, damage, or injury, including death that may be sustained by me, or to any property belonging to me, or both including but not limited to any claims, demands, actions causes of action, judgements, damages, expenses and costs, including attorneys fees, which arise out of, result from, occur during or are connected in any manner with my participation in said program or any related travel or activities, including such loss, damage, injury or death that may result from RELEASEES own negligence, and I further WAIVE any right I might otherwise have and COVENANT NOT TO SUE said RELEASEES in connection with any such liability. I am fully aware of risks and hazards connected with participation in independent international academic work/research, and related activities, including but not limited to exposure to infection and infectious diseases, rebellion, political unrest, internal turmoil, traffic accidents, and crime, which could result in serious or mortal illness, injuries and property damage, and am fully aware that there may be risks and hazards unknown to me connected with such participation, and I hereby voluntarily elect to participate in international academic work/research, and related activities, knowing that conditions may be hazardous or dangerous to me and my property. I am also aware that there are additional hazards attendant to traveling in foreign countries, including but not limited to problems that may arise because I may not be a citizen of the countries and areas being visited, because I may not be fully conversant with the language spoken in and cultural practices of those countries and areas being visited, because I will be subject to the laws or regulations of the country visited, and because of the world wide potential danger of terrorist attacks. I am fully aware that international academic work/research can be physically and mentally rigorous, and the possibility of illness, accident or death is always a concern. Furthermore, I am aware that the University of Florida strongly recommends that I receive assurances from a physician regarding the rigors of travel as they relate to any special conditions and/or needs I may have. I understand that the program does not routinely employ health professionals, and I recognize that it is my responsibility, and not the responsibility of RELEASEES, to secure any physical or mental health support I may require while abroad. I am fully aware that most US health insurance coverage provides very limited coverage abroad and does not provide for direct payment for medical services abroad and that I likely will have to make payments and file a claim with my insurer upon my return to the US. Furthermore, I recognize that it is my responsibility, and not the responsibility of RELEASEES, to understand the limits of my major medical health insurance coverage and to ensure that my policy provides sufficient coverage for my needs and is effective during the entire period of my stay abroad and participation in the program. I have purchased Emergency Assistance Insurance (MEDEX) to cover me during the entire period of my stay abroad. I further hereby AGREE TO INDEMNIFY, DEFEND AND SAVE AND HOLD HARMELESS the RELEASEES and each of them, from any loss liability, damage or costs including court costs and attorneys fees they may incur as a result of any claims, demands, actions, causes of action, damages or judgements, which arise out of, occur during, or are in any way connected with my participation in the program or any related travel or activities. In signing the release I ACKNOWLEDGE and REPRESENT that: I have read the foregoing release, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; I execute this release for full, adequate and complete consideration fully intending to be bound by the same and intending to bind my heirs, successors, assigns, personal representative and estate; I have been approved to engage in international academic work/research by my faculty supervisor and Chair; I agree that this Release, Indemnification, Waiver and Hold Harmless Agreement is to be construed under the laws of the State of Florida, U.S.A. and the venue shall be in Alachua County Florida. If any portion hereof is held invalid, the balance hereof shall continue in full force and effect. Signature of Applicant: Printed Name: Department/College: Date: UFID : Term & Year:

4 PREFACE UNIVERSITY OF FLORIDA POLICY STATEMENT ON ALCOHOL AND OTHER DRUGS The University of Florida is committed to providing an environment free of the abuse of alcohol and illegal use of alcohol and other drugs. To enhance this commitment, the University has adopted and implemented programs that seek to prevent the illicit use of drugs and the abuse of alcohol by University community members. Please refer to the current U.F. Student Guide, available from Dean of Students Office or the Study Abroad Services office for a complete copy of the policy. STANDARD OF CONDUCT The unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance or the unlawful possession and use of alcohol is harmful and prohibited in and on property owned or controlled by the University of Florida or any other University of Florida facility. No employee or student is to report to work, class, or any University activity while under the influence of illegal drugs or alcohol. The use of alcoholic beverages by members of the University of Florida community is at all times subject to the alcoholic beverage laws of the state of Florida, city of Gainesville, county of Alachua, or other applicable local regulations and the University Alcohol Policy, Rule 6C , Florida Administrative Code. The possession and use of controlled drugs by members of the University of Florida community must at all times be in accordance with the provisions of Florida law, the rules of the Board of Regents, and the rules of the University of Florida. Under Florida law, no person may possess substances regulated under the provisions of Chapter 893, Florida Statutes (controlled substances and "designer drugs"), unless dispensed and used pursuant to prescription or otherwise authorized by law. Sale and delivery of such substances is prohibited unless authorized by law. UNIVERSITY OF FLORIDA SANCTIONS Violation of the policies and laws described above by an employee or student are grounds for disciplinary action up to and including termination or expulsion in accordance with applicable University of Florida and Board of Regents rules and/or collective bargaining agreements. Student organizations also may be sanctioned for violation of these policies and laws. Additionally, a violation may be reason for evaluation/treatment for a drug- and/or alcohol-use disorder or referral for prosecution consistent with local, state, and federal criminal law. Disciplinary action against a student or employee by the University does not preclude the possibility of criminal charges against that individual. The filing of criminal charges similarly does not preclude action by the University. STUDY ABROAD SERVICES STANDARDS It is recognized that many countries have differing laws and regulations regarding alcohol and drug use. Students should be aware that participants in University of Florida Study Abroad Services programs are expected at a minimum to abide by the UF standard of conduct AND to adhere to all local laws wherever the program may be held. Participants should also recognize that many host countries have stricter and more severe penalties associated with the enforcement of their laws over which neither UF nor US agencies have any influence. Students who are found to be disruptive due to abuse of alcohol and drug use or who are adjudicated within the host country as having violated local regulations/laws will be dismissed immediately from the U.F. Study Abroad Services Program and, upon their return to the U.S., will be subject to any and all actions as deemed appropriate under the University of Florida or their home school Student Conduct Code. Signature of Applicant: Printed Name: Date: UFID: Department/College: Term & Year: Revised: 07/24/01 G:\Medex\Alcohol & Drug Policy.doc

5 Check List for Independent International Academic Work/Research UPON COMPLETION, RETURN TO FACULTY ADVISOR OR DEPARTMENTAL SUPERVISOR FOR RETENTION Reviewed with Sponsoring UF Department: Discussed with my departmental supervisor and received approval for this independent international academic work/research experience. The name of my departmental supervisor is:. Provided my departmental supervisor with my flight itinerary, location in country, emergency contacts and a copy of my passport. Reviewed with UFIC Study Abroad Office: Reviewed U.S. State Department Travel Advisory and Warnings ( UFIC recommends no travel to countries in which a Travel Warning is in effect. Received and signed UF Policy Statement on Alcohol and Other Drugs. Received and signed Release, Indemnification, Waiver, and Hold Harmless Agreement. Enrolled in and purchased medical evacuation insurance (Medex). Student s Responsibility: Reviewed U.S. State Department Consular Information Sheets ( Ensured passport validity or followed U.S. State Department instructions for passport application and have obtained passport. Reviewed foreign entry requirements for visa and obtained visa if required. Verified that health insurance will cover me abroad. Reviewed Center for Disease Control (CDC) foreign travel immunization requirements, recommendations and received any necessary immunizations required for travel to country of destination ( Student Name: Print Name Student Signature: Date: UFIC Signature: Date: Department Signature: Date: G:\SAS Medex\Medex application form - 1.doc