Study Abroad Costa Rica 2016

Transcription

1 How to turn in this application: Scan and to Study Abroad Costa Rica 2016 Fax to Attn: Carol Koch. Mail Colorado Mountain College Attn: Carol Koch 150 Miller Ranch Road Edwards, CO Important Information: Trip departs June 4, 2016 An application fee of $100 is due upon submission of the application and is nonrefundable. The last day to submit application is April 1, 2016 along with 50% of the program fee. The full balance is due on May 2, 2016 You must be 18 years old at time of departure. Check or credit card are acceptable for deposit payments. Credit card payments can be made in person or over the phone. See the Payment information section for more information. Personal Information Name Address Home phone Cell phone Occupation DOB Passport # Expiration Date Are you a current CMC student? Yes No This program includes a homestay with a Costa Rican family. Please indicate your preferences. Family with children Yes No No preference Family with pets Yes No No preference Emergency Contact Name Address Home phone Cell phone

2 Health Information Health provider s name Health provider s address Health provider s contact info Do you have any medical conditions and/or allergies that we should be aware of? If yes, explain No Do you require special services or accommodation for any disability? If yes, explain No Are you taking any medication If yes, explain No List any medical or religious restrictions regarding diet or other activities. Tell us about your special interests and hobbies. Where did you hear about the program? Students must be in good academic standing with CMC to participate In Study Abroad programs and applicants will be reviewed prior to May 2nd. Are you currently having academic problems that could prevent you from participating? If yes, explain No

3 Spanish Language *It is not necessary to have prior coursework or contact with Spanish to participate in this program. List all Spanish coursework that you have completed or is in progress. Also, describe your Spanish use (if any) in the workplace, at school, at home etc. Please contact Carol Koch for questions concerning Spanish Language Placement Payment Information Program fee $ (50% due on April 1 st -100% by May 2 nd ) The program fee includes: Spanish classes in Costa Rica Home stay with a Costa Rican family 2 meals per day with family. Students opting to travel independently on the weekends will have to cover their own costs of food and lodging, Arrangement of Service Learning Projects Emergency Travel Insurance Through Colorado Mountain College Travel between San José and San Isidro, Heredia at the program s beginning and end. AIRFARE NOT INCLUDED CMC Tuition Students must register for SPA 194 (3credits) through CMC. Tuition is paid separately from the program fee upon registration $171 In District $309 CMC Service Area $321 In-State $1,119 Out of State Additional Student Costs Not covered as part of the program fee, or tuition are items such as:: Flights to and from the USA to San José, Costa Rica If students are not able to be at Aeropuerto Internacional Juan Santamaría in San José, Costa Rica at the designated pick up times, they will have to find transportation to San Isidro, Heredia. Independent Travel Independent lodging (weekends) Independent food Souvenirs Phone calls Independent recreational activities Payment of program fee and timeline A $100 Application fee is due on submission of application 50% of the program fee is due on or before April 1, % is due on or before May 2, 2016 Payment may be made in person, over the phone or via mail. o For phone payments, contact Wendy Wotring (970) o Mailed payments and applications should be sent to Carol Koch / Colorado Mountain College / 150 Miller Ranch Road / Edwards, Colorado / 81632

4 Refunds and Cancellation: Course refunds are subject to the course refund and cancellation policies of Colorado Mountain College. Program fees however, are fully refundable if requested before close of business (COB) May 2, 2016, are refunded at 50% if requested by COB May 13, 2016 will become non-refundable as of May 14, Appeals may be available for program fee remission based on cancellation due to extenuating circumstances. Student Conduct Colorado Mountain College has established a Student Participation Agreement outlining expectations of conduct and preparation for international travel. This Student Participation must be turned in along with your application, and is attached to the application for your convenience. Agreement and Signature I have supplied accurate information. I understand that proof of health insurance (with international coverage) will be required by the due date of the final payment. I understand my financial obligations and payment due dates. I have read, understand, and have signed the Student Participation Agreement and have included it with this application. I understand that I need to selfreliant, independent and be able to take care of myself during travel and study. I understand that if my behavior s disruptive or inappropriate at any time during the study abroad trip, I will be sent home at my own expense. I have read and agree with the terms presented on this application form. Signature Date

5 Colorado Mountain College Student Participation Agreement Program Name: Costa Rica Study Abroad Program Instructor: Carol Koch In partnership with: Common Ground International Destination(s): Costa Rica Course Dates: June 4-June 26 My participation in this activity is conditional upon the following: 1. I agree to follow the laws of Costa Rica at all times while in-country. 2. I will not possess or use illegal drugs at any time during travel. I understand that this could have serious consequences, including lengthy incarceration, and that neither CMC, partnering organizations, or the U.S. Government will be able to assist me if I am arrested or detained for illegal drug use or possession. 3. I agree to register my travel details with the U.S. State Department Smart Traveler Program prior to departure ( 4. I agree to carefully review all orientation materials provided by CMC, Common Ground International, and the Costa Rica background and health information provided by the U.S. State Dept I agree to adhere to all written and verbal instructions, rules, and expectations given by the course instructor, partnering organization instructors, administrators and host families. 6. I agree to promptly provide all completed forms and documentation requested by the course instructor and partnering organization. 7. I understand that the program fee INCLUDES See page 3 of this application form. I also understand the trip fee EXCLUDES See page 3 of this application form. 8. I understand that travel delays and changes to the travel and course itineraries can occur at any time, and I agree that CMC and any partnering organizations are not responsible for any issues, inconveniences, or additional expenses that result from cancelations, delays, or itinerary changes. Political instability, environmental conditions, health emergencies, or other regional activities may impact the viability and safety of a trip, requiring immediate itinerary modification or cancellation at any time, including during the trip. 9. I understand that I am traveling to a region where climate, weather, food, water, accommodations, and political, legal, and cultural norms may be different than home and what I may be accustomed to. I will do my best to adjust my expectations and adapt to these differences in the spirit of learning and exploration. 10. I agree to participate fully in all course-related activities. I understand that full participation includes conduct during free time that won t hinder my ability to focus and actively participate in activities later (i.e., get sufficient sleep and avoid excessive alcohol consumption, etc.). 11. I agree to keep in good communication with the course instructor, partnering organization instructors and host families regarding any concerns I may have about my participation or activities. 12. During free time, I agree to communicate my plans (including destination and time frame) to the course instructor and/or partnering organization staff or host families; to take only legitimate, safe transportation (which will be established by faculty director or host family), and to be especially cautious about going out at night. I also agree to abide by limitations to free time activities that may be established by the course instructor or host families.

6 13. I will demonstrate respect and consideration for the course instructor, partnering organization instructors, administration and host families, other participants in the program, and the citizens of the host country. 14. I understand and agree that failure to adhere to the terms of this agreement may result in the immediate termination of my participation in this program and that I may be sent home at my own expense. Printed Name: Signature: Date:

7 COLORADO MOUNTAIN COLLEGE ASSUMPTION OF RISK, WAIVER AND RELEASE FROM LIABILITY Name: Date of Birth: Phone/Contact: CMC Student ID#: Emergency Contact Name: Emergency Contact Phone: Course Instructor: Course/Activity: Date(s) of Course/Activity: I wish to participate in the above activity at Colorado Mountain College (the Activity ). I voluntarily and knowingly choose to participate in this Activity despite its risks. In consideration for being permitted to participate in the Activity, I agree as follows: 1. Risks. I understand that the Activity involves various risks, hazards and dangers, including risks of physical injury, disability, or death and risk of loss of use or damage to my personal property. I affirm and acknowledge that I have been sufficiently informed of and understand the inherent hazards and risks associated with this Activity. I also understand that injury or loss may result from unknown or unexpected risks. These risks may result from the use of equipment, materials, or facilities owned by CMC or others; from the activity itself; from travel away from CMC campuses; from environmental conditions; from the acts or omissions of others; or from the unavailability of immediate emergency medical care. 2. Assumption of Risks. Knowing the risks, I HEREBY ASSUME ALL RISKS that may arise out of or result from the Activity, including but not limited to the risks described above. 3. Release, Waiver, Indemnity. I HEREBY RELEASE, WAIVE, DISCHARGE, INDEMNIFY, DEFEND, HOLD HARMLESS, AND AGREE NOT TO SUE COLORADO MOUNTAIN JUNIOR COLLEGE DISTRICT, ITS BOARD OF TRUSTEES, OFFICERS, INSTRUCTORS, EMPLOYEES, AGENTS, VOLUNTEERS, AND ANY STUDENTS ACTING AS LEADERS, ORGANIZERS OR EMPLOYEES, FROM, FOR, OR AGAINST ANY LIABILITY, CLAIM, DEMAND, SUIT, OR CAUSE OF ACTION OF ANY KIND, FOR ANY PROPERTY DAMAGE, LOSS OR THEFT, PERSONAL INJURY, DEATH, OR DISABILITY, OR OTHER LOSS OR EXPENSE OF ANY KIND ARISING OUT OF OR IN CONNECTION WITH THE ACTIVITY, EXCEPT ONLY FOR DAMAGE, INJURY, OR LOSS CAUSED BY THE GROSS NEGLIGENCE OR WILLFUL MISCONDUCT OF CMC. 4. Safety, Policies and Procedures. I understand that CMC takes reasonable efforts to make the Activity safe, but I also recognize that it is impossible for CMC to guarantee my safety, to fully protect me from harm or injury, or to guarantee that the Activity will proceed exactly as planned. I understand and agree that safety is a shared responsibility, and as a participant, I have a duty to act with reasonable caution, to be observant of unsafe conditions, to report any unsafe conditions to CMC; and to follow all CMC safety and other rules, standards, and instructions for the Activity. 5. Transportation. I understand that CMC is providing transportation to and from this Activity. However, if for any reason I voluntarily agree to drive my own personal vehicle to and from the event, I understand that personally owned vehicles used in conjunction with this Activity are not covered by CMC insurance for property damage or liability. I understand that I am required to carry vehicle liability insurance required by the State of Colorado. 6. Prerequisite Skills/Abilities. I affirm that I have the prerequisite skills, knowledge, and physical ability necessary to properly and safely participate in the Activity and to use the equipment and facilities involved in the Activity. If I have any questions or concerns about my abilities to participate in the Activity safely, I will ask CMC staff. 7. Health and Medical Insurance. I certify that I have no medical or health-related problems which would preclude or restrict my participation in this Activity. I acknowledge that I have been advised to consult with a doctor if I have any concerns about my ability to participate in this Activity. I understand that CMC does not carry any insurance that would cover any injuries or losses I may suffer while participating in this Activity including evacuation costs. I acknowledge that I am solely responsible for any and all costs of medical treatment or evacuation costs required by me or on my behalf, I agree to pay for such medically related treatment and evacuation services, and I assume all risks of such expenses. 8. Consent for Emergency Treatment. In the event I am injured or become ill during the Activity, I authorize CMC to administer basic first aid, authorize or obtain appropriate medical care and treatment for me, to make medical decisions in my behalf, to place me in the care of a local medical doctor, or to place me in a hospital for any necessary medical treatment, all at my expense. 9. Publicity/Image/Voice Permission. I understand that CMC may take photographs, video, and/or audio recordings of our field trips. Unless you request otherwise, your signature on this document will be considered permission for CMC to photograph, film, video, and record your image and/or voice for use in CMC publications or promotional materials. If you object to CMC using your image and/or voice in this manner, please notify the instructor and initial this section. I DO NOT GIVE PERMISSION TO USE MY IMAGE OR VOICE IN PUBLICATIONS OR PROMOTIONAL MATERIALS AND WILL NOTIFY THE CMC INSTRUCTOR PRIOR TO THE FIELD TRIP. PLEASE INITIAL HERE 10. Binding Effect. I intend this Release to be fully binding on me and my heirs, successors, assigns, and personal representatives. 11. General Provisions. This Release shall be construed in accordance with the laws of Colorado. Venue for any legal action concerning this Release shall be in Colorado. If any term or provision of this Release is held illegal or unenforceable, all remaining provisions of this Release shall remain in full force and effect. I am not relying on any oral or written representation, statement, or promise other than what is set forth in this Release. I hereby acknowledge that I have fully read and understand this Release, and I agree to be bound by it. I realize it relates to surrendering and releasing valuable legal rights. I sign it knowingly and voluntarily and of my own free will. I affirm that I am at least eighteen (18) years of age and fully competent to sign this Release, or if not, my parent or guardian is also signing this Release on the reverse side. STUDENT/PARTICIPANT: Date: Signature NOTE Retention Policy: CMC is required to retain completed waivers, electronic or hard copies, for seven years

8 Minor Student/Participant Under 18, Additional Signatures Required A. I am the Parent/ Guardian of Student/Participant who is under eighteen years of age and am fully competent to sign this Agreement. I give permission for Student/Participant to participate in the above-referenced Activity. I execute this release voluntarily and knowingly for full, adequate and complete consideration fully intending for myself, the Student/Participant, and for Participant s family, estate, heirs, administrators, personal representatives, or assigns to be bound by the same. PARENT/GUARDIAN: Date: Print Name Signature B. I, the Course Instructor agree to allow the above named minor Student/Participant to participate in the above named Activity. I further acknowledge and certify that I have consulted with the Academic Supervisor and that he/she also gives approval to allow the Student/Participant to participate in the above named Activity and that College policy concerning participating minors have been followed. COURSE INSTRUCTOR: Date: Print Name Signature NOTE Retention Policy: CMC is required to retain completed waivers, electronic or hard copies, for seven years