Experience Europe 2016 College of Business and Communication Application - Due February 5,2016

Transcription

1 - Due February 5,2016 Complete, sign, and submit this application along with your letter of intent to BYU-Idaho, College of Business and Communication, Smith 229, Rexburg, ID Fax (208) Full Name (same as passport) Gender M/F BYU-I ID # Track Attending Preferred Name Citizenship Phone ( ) Date of Birth BYU-I (required) This is the main method of communication. Alternative Academic Major Academic Minor/Emphasis Year at BYU-I Freshman (0-30 credits) Sophomore (31-60) Junior (61-90) Senior (91-120) Parent/Guardian Name Phone ( ) In case of emergency, notify (if different from parent/guardian): Name Relationship Phone ( ) STUDENT COMMITMENT If accepted as a member of this program, I promise to: 1. Support and uphold the moral standards and ideals of the LDS Church. 2. Follow the behavior, dress, and grooming codes of BYU-Idaho. 3. Abide by the decisions of the tour directors in all matters pertaining to the tour. 4. Accept the will of the majority whenever a matter of choice presents itself. 5. Fill out a physical and mental health information and release form before final acceptance. 6. Make payments according to the following schedule: Your BYU-Idaho account will be charged the full $4,200. A $500 non-refundable payment to your account is due by March 1, 2016 to secure your space on the trip. Failure to make this payment may result in cancellation of your reservation for the trip. The remaining $3,595 will be due on or before September 1, In case of cancellation you will lose the non-refundable, $500 payment as well as any additional payments/costs incurred at that point in the planning and preparation for the trip. There are no exceptions to this policy. I understand I may be sent home at my own cost if I fail to adhere to these regulations. Signature of Applicant Date: Signature of Parent/Guardian Date: (Participants under 18 or financially dependent upon parents/guardians must have parental/guardian approval.)

2 LETTER OF INTENT Name: Either on this form or as an attachment please describe your interest in and motivation for the Experience Europe Why do you want to go? What do you hope to learn and accomplish? What will you contribute?

3 ASSUMPTION OF RISK AND RELEASE AGREEMENT I know and recognize that participation in the Experience Europe 2016 conducted by Brigham Young University-Idaho is done on a voluntary basis without compulsion or coercion and is not a mandatory class requirement. (However, if one chooses to tour, one must take at least three credits.) I know there may be dangers and hazards associated with the tour and assume the risks associated with participation in the tour, including but not limited to: Hazards associated with travel, whether by land, sea, or air including airplane, auto, or bus crashes; hazards of hiking, biking, snorkeling, and swimming, such as falls, crashes, being struck by a vehicle, drowning, or suffering physical exertion; hazards of unstable governments and related potential violence; hate crimes; illness caused by food, water, heat, cold, altitude, or contagious disease; assault, theft, or robbery; trip cancellation or change in itinerary and travel plans; acts of God; any activity I decide to participate in during free time. I acknowledge that these hazards could cause physical or emotional harm or even death. Knowing the risks, and in consideration for being permitted to participate, and as inducement to Brigham Young University-Idaho to permit me to participate on this tour, I hereby, for myself, my heirs, executors, administrators, or anyone else who might claim on my behalf, covenant not to sue, and waive, release, and discharge Brigham Young University-Idaho, its agents, officers, and employees from any and all claims or liability for death, personal injury or property damage of any kind or nature, and any other claims whatsoever arising out of or in any way connected with my participation in this tour, even though liability may arise out of carelessness on the part of Brigham Young University-Idaho, including its officers and employees. This release extends to all claims of every kind or nature whatsoever, foreseen or unforeseen, known or unknown. MY SIGNATURE BELOW AFFIRMS THAT I HAVE CAREFULLY READ THIS ASSUMPTION OF RISK AND RELEASE AGREEMENT AND THE OTHER TERMS; I UNDERSTAND ITS CONTENTS AND PURPOSES, AND VOLUNTARILY AGREE TO ALL THE TERMS SET FORTH ABOVE. Participant signature Date Witness signature Date Parent/guardian signature Date (Participants under 18 or financially dependent upon parents/guardians must have parental/guardian approval.)

4 STUDENT HEALTH FORM AND MEDICAL HISTORY Legal Name: (First) (Middle) (Last) Personal Medical History Your Health Problems Y N Your Health Problems Y N Your Health Problems Y N Allergies Joint/Muscle Problems High Blood Pressure Asthma Back Problems Eating Disorder Colitis Heart Problems ADD/ADHD Diabetes/Hypoglycemia Stomach Trouble/Ulcers Schizophrenia Hernia Thyroid Problem Claustrophobia Hives or Rashes Seizures Dementia Reactions to Drugs Suicidal Thoughts Acrophobia Heat Reactions Depression Obsessive-Compulsive Hearing Loss Anxiety/Panic Attacks PTSD Currently receiving counseling Yes: No: Other: (Please list) If yes to any of the above questions, please explain: Are you currently taking medication? If yes, please indicate what medication and if you will be taking it on the tour.

5 Consent of Treatment I understand and agree that BYU-Idaho will not have medical personnel available at the location of the program. I further agree that BYU-Idaho personnel and students are granted permission to provide and authorize emergency medical treatment, if necessary, and that such actions are subject to the Assumption of Risk and Release Agreement which I have signed and that they shall assume no responsibility for any injury or damage which might arise out of or in connection with such emergency medical treatment. In the event of my injury or illness, I also authorize BYU-Idaho to select a physician(s) to administer surgical treatment or carry out such procedures as may be deemed necessary or advisable to diagnose and treat me during the course of my participation in Experience Europe Travel Study. I freely give this medical information to my directors, knowing that they will keep it in the strictest confidence. Signed: Co-Signature of parent/guardian if student is under 18 yrs. of age