Application and Contract for Clayton State University Maymester 2018 Study Abroad Guadalajara, Mexico Healthcare & Service Learning MAY 9-17, 2018 Directions: Please complete ALL items (type or print), sign, and return this completed application to Dr. Colleen Walters, CE 214 C, or mail to: Dr. Colleen Walters, DNP, NP-C, CNE Harry S. Downs Center for Continuing Education & the College of Health, CE 214 C School of Nursing 2000 Clayton State Boulevard Morrow, GA 30260-0285 I. PAYMENT SCHEDULE AND REFUND POLICY: All payments must be made to the Bursar s Office in Edgewater Hall First Payment & Deposit: Monday, January 29, 2018, of $500.00 Second Payment: Monday, March 12, 2018, of $700.00 Final Payment: Monday, March 26, 2018, of $500.00 *The charges above reflect the cost of the study abroad program only! Tuition for the course(s) associated with this study abroad program is additional. *See section X below for more information. Maymester Refund Policy: Withdrawal on or before Monday, February 12, 2018: Complete refund excluding the non-refundable deposit of $250.00. Withdrawal after Monday, March 12, 2018: Costs for airfare, rail, admissions, and hotel(s) (including any cancellation penalties or charges imposed by the airline, hotel, or other prepaid expenses) and all administrative fees incurred are forfeited: the remainder will be refunded, excluding the non-refundable deposit of $250.00. Withdrawal on or after Monday, March 26, 2018: All costs are forfeited; no refunds. Maymester NOTES Health Clearance Form: STUDENTS MUST MAKE SURE THAT THE REQUIRED HEALTH CLEARENCE FORM HAS BEEN APPROVED & CLEARED. IF YOUR HEALTH CLEARENCE HAS BEEN DENIED BY YOUR PHYSICIAN PAY CLOSE ATTENTION TO THE WITHDRAWAL DATES. Students should complete the Health Clearance Form before Monday, March 12, 2018, in order to receive a full refund, excluding the non-refundable deposit of $250.00. Remember, this form must be mailed by your physician or University Health Services (UHS) to the Clayton States Office of International Programs. Add/Drop/Withdrawal Periods from the Course: Students who are considering dropping the course need to refer to the Academic Calendar for the current semester to review add/drop dates, withdrawal dates, etc. to make sure these dates do not affect your withdrawal process from the study abroad program. If you have questions or concerns, speak with your Academic Adviser and Program Director. The Academic Calendar can be located here: http://www.clayton.edu/calendar Requests for refunds and withdrawal from the program must be made in writing to the Office of International Programs. If program withdrawal is necessary for extenuating circumstances (Hardship Withdrawal), refunds will be considered on a case by case basis. All students must register and pay in full for the program fees and course tuition by the final payment deadline or they will be dropped from the program. Students will receive a full refund if the program is cancelled due to lack of participants. Page 1 of 7
A $500 deposit must be received by the Bursar s Office in the Student Center Building by 01/29/2018 in order to confirm registration. Deposits will be credited toward program costs. See Paragraph VIII below for additional details about Payment Schedule and Refund Policy. Applications will be accepted for this program until March 12, 2017. This course is limited to 10 participants. II. PERSONAL INFORMATION (Please list name exactly as it appears on passport/identification): Last Name First/Middle Street Address City/State/Zip Code ( ) ( ) HOME Telephone Number WORK or CELL Number CSU E-Mail address Date of Birth (mo/day/yr) * Gender (M/F) Laker I.D. (or SSN if not CSU student) *All participants must be 18 years of age prior to the program departure. III. EMERGENCY CONTACTS: Name Address E-Mail address Name Address E-Mail address ( ) ( ) Telephone # Relationship Telephone # Relationship May we speak with your parents about the program? Yes No IV. PASSPORT INFORMATION: Country of Citizenship YES, have passport, # City Issued Expiration Date NO, am applying for passport ALL PARTICIPANTS MUST HAVE A VALID PASSPORT TO TRAVEL PLEASE PROVIDE A COPY WITH YOUR APPLICATION OR SUBMIT A COPY AS SOON AS YOU OBTAIN YOUR PASSPORT. It is the responsibility of the participant to ensure they have valid travel documentation such as a passport, visa, etc., required for the countries visited on their study abroad program. Students who are unable to travel due to lack of a valid passport, visa, or other documentation will not be entitled to refunds other than those allowed by the dates listed in this contract. Page 2 of 7
V. ACADEMIC INFORMATION: College/university currently attending: Class Standing Major/Area of academic interest: G.P.A. Are you enrolled in a program leading to a degree or diploma? Yes No STUDENTS MUST BE IN GOOD ACADEMIC STANDING THE SEMESTER PRIOR TO DEPARTURE. CLAYTON STATE REQUIRES A MINIMUM GPA OF 2.0 FOR UNDERGRADUATES TO BE IN GOOD ACADEMIC STANDING. INDIVIDUAL STUDY ABROAD PROGRAMS, HOWEVER, MAY REQUIRE A HIGHER GPA. I understand that, in order to participate, I must be in good academic standing the semester prior to program departure and have met all course prerequisites. I understand that my standing may be checked. If I am not in good academic standing the semester prior to program departure or have not met the course prerequisites, I will not receive credit for the program. VI. MEDICAL INFORMATION: NOTE: STUDENTS MUST MAKE SURE THAT THEIR HEALTH CLEARENCE FORM HAS BEEN APPROVED & CLEARED. IF YOUR HEALTH CLEARENCE HAS BEEN DENIED BY YOUR PHYSICIAN PAY CLOSE ATTENTION TO THE WITHDRAWAL DATES. Students should look at completing the Health Clearance Form before Monday, March 12, 2018, in order to receive a full refund, excluding the non-refundable deposit of $250.00. Remember that the form must be mailed to the Study Abroad Office from your medical provider, it can t be delivered in person by the student, please make sure to allow ample time for delivery as it must be mailed by the physician or University Health Services (UHS) at Clayton State to the Office of International Programs. Supplemental health insurance is included in the cost of the program (see health insurance brochure for details of coverage). VII. RELEASE AND WAIVER OF LIABILITY: I acknowledge that participation in a study abroad travel program involves some risks of injury, illness, or loss of personal property. I agree to release and forever discharge the Board of Regents of the University System of Georgia (including USG member institutions), its members individually and its officers, agents and employees from any and all claims, demands, rights and causes of action of whatever kind or nature arising from, and by reason of any and all known and unknown, foreseen and unforeseen bodily and personal injuries including death, damages to property and the consequences hereof resulting from my participation in Maymester 2018 Study Abroad. I further certify that, to the best of my knowledge, I am in good health and physically capable of undertaking an intensive program of foreign study. I hereby authorize the program director to obtain necessary medical treatment or services for me at my expense. Further, I understand that this Release and Waiver of Liability shall be effective for a period of one year from this date. VIII. APPROPRIATE CONDUCT AND EARLY DISMISSAL FROM THE PROGRAM: I understand that participants in Maymester 2018 Study Abroad are required to exhibit appropriate conduct while participating in the program and that the program director has full authority to determine the appropriateness of participants' conduct. Appropriateness will be judged based on local laws, regulations, customs, and on program rules and schedules. I acknowledge that if the program director finds my conduct inappropriate, he/she may at his/her discretion order my early dismissal from the program. Dismissal means that I will be sent home as soon as is practical in the program director's judgment, will be billed for the cost of the unscheduled early trip, and will receive no refund on participant fees paid into the program. IX. TRIP CANCELLATION/INTERRUPTION INSURANCE: The participant may wish to obtain trip insurance to protect their financial investment in a study abroad program. This generally includes financial protection in the event that a participant must withdraw from the program for a covered reason. This protection Page 3 of 7
is optional and is not offered by Clayton State University. Students who are interested in this protection should obtain it from a third party provider. Please contact the Office of International Programs should you require more information. Clayton State is not liable for any costs associated with withdrawing from the program outside of the refund schedule included in this contract. In the event that there are more applicants than available spots in the program, the course director has discretion to decide which students will be allowed to participate based on the date that the Application and deposits were received, academic standing/gpa, and completion of prerequisites. X. COURSE REGISTRATION AND PAYMENT OF TUITION It is the student s responsibility to ensure they are enrolled in the correct academic course associated with their study aboard program. Please contact your program director for more information. Tuition for courses associated with study abroad programs is NOT included in the program cost. Tuition is charged separately at the time of course registration. Students must abide by the tuition payment deadlines set forth by Clayton State University for the semester of your study abroad course registration. Students who are dropped from courses associated with study abroad programs will not be allowed to travel with the study abroad program. XI. ADDITIONAL CONDITIONS SPECIFIC TO THE GUADALAJARA PROGRAM: I understand that this course involves studying and staying in a Spanish-speaking developing country with a tropical climate. It is NOT a resort. Facilities are more than adequate, but basic. Homestays are arranged with Mexican families. There is no air conditioning and rooms are shared. Meals with be prepared by the Mexican family and students are encouraged not to eat on the streets due to the risk of gastrointestinal infections common in this region. Dietary restrictions must be communicated prior to departure and accommodations will be made. Adequate intake of water must be maintained to decrease risk of dehydration. I understand that this course involves daily outdoor activities and my physical condition needs to be such so that I can tolerate moderate hiking, walking, and climbing steps. I understand that if I choose to withhold medical history information that places me at increased risk for illness or injury as a result of participating in this study abroad program, Clayton State University is not liable and I may be sent home with a grade of zero after receiving any needed medical care. XII. I certify that ALL the above information is true and correct to the best of my knowledge. I have read, understand, and fully accept ALL of the above terms or conditions for participation in the Maymester 2018 Study Abroad. XIII. Signature of Applicant Date XIV. Signature of Program Director Date Page 4 of 7
STATE OF GEORGIA COUNTY OF CLAYTON CLAYTON STATE UNIVERSITY STUDY ABROAD PROGRAMS ASSUMPTION OF RISK, COVENANT NOT TO SUE AND INDEMNIFICATION I, the undersigned, (the Participant ), am participating in the CLAYTON STATE UNIVERSITY Study Abroad Program in between the dates of and. This Study Abroad Program is not a requirement of my course of study at CLAYTON STATE UNIVERSITY and my participation in it is purely voluntary. As such, I agree to assume all risk involved with my participation in this Study Abroad Program. I acknowledge that the study abroad experience involves risks such as accidents, illness, disease, poor sanitation, inadequate medical care and facilities, terrorism, crime, the hazards of travel, natural disasters, and other hazards arising from a wide variety of events and circumstances which cannot be enumerated. I voluntarily assume all such risk. In consideration of the professional and educational enrichment and academic credit that I will derive from this educational, and other valuable consideration the receipt whereof is hereby acknowledged, I do also hereby, for myself, my heirs, executors, administrators, and assigned, waive, release, covenant not to sue and forever discharge the Board of Regents of the University System of Georgia and CLAYTON STATE UNIVERSITY and their members, agents, servants and employees and the individual(s) responsible for, and employed by, the Program and their agents (each of the foregoing being hereinafter referred to as the "University") of and from any and all manner of action or actions, causes or causes of action, including, but not limited to negligence, suits, debts, accounts, damages, claims and demands of whatsoever in law, in admiralty, or in equity or otherwise, which I have or may acquire by reason of injury, damage or harm to person while participating in said travel and/or study program or study programs, arising out of, or connected with, participation in said travel and/or study program or study programs. Further, I agree to defend, indemnify and hold harmless the University from any and all claims, demands, and/or causes of action arising out of my own actions while participating in the Program. I understand and agree that the University accepts no responsibility if a Program is cancelled before departure or while the program is in progress for reasons beyond the University s reasonable control including, but not limited to, political unrest or perceived danger to participant safety. The University reserves the right to cancel or change the Program in any way accordingly, in which event the undersigned agrees to hold the University harmless for any prepaid Program fees. The University will make a reasonable effort to obtain refunds from service providers such as hotels, airlines, and dormitories of all prepaid Program expenses and, to the extent such refunds are received by the University; they will be refunded to Program participants. Fees paid will only be refunded to Program participants to the extent they are refunded to the University and assumes no responsibility for the financial losses of Program participants. I understand and acknowledge that the University assumes no responsibility or liability, in whole or in part, for any delays, delayed or changed departure or arrival times, fare changes, dishonors of hotel, airline or vehicle rental reservations, missed carrier connections, sickness, disease, injuries (including death), losses, damages, weather, strikes, acts of God, circumstances beyond the control of the University, force majeure, war, quarantine, civil unrest, public health risks, criminal activity, terrorism, expense, accident, injuries, damage to property, bankruptcies of airlines or other service providers, inconveniences, cessation of operations, mechanical defects, failure or negligence of any nature howsoever caused in connection with any accommodations, restaurant, transportation, or other service or for any substitution of hotels or of common carriers beyond the University's control, with or without notice, or for any additional expense occasioned by any of the foregoing. I agree to abide by all deadlines for fee payment, application materials, and health documentation for my Program. I further acknowledge and accept the schedule for refunds, should I withdraw from the Program, and accept the penalties associated with late withdrawal. I understand that all withdrawals must be made in writing. I acknowledge that I have received and read the Refund Policy Form and I agree to maintain accident, health, medical evacuation and repatriation of remains insurance in force and effect for the entire duration of my participation in the Program. I further certify that, to the best of my knowledge, I am in good health and physically capable of undertaking an intensive program of foreign study; any medical or health-related problems have been explicitly described to the program director in Page 5 of 7
the Physician's Certification provided by me to the Program Director. I understand and acknowledge that a condition of eligibility for participation in the University Study Abroad Program for which I have applied is obtaining all vaccinations required for direct travel from the United States to my Program country(ies). I further acknowledge that the University strongly encourages Program Participants to obtain all vaccinations recommended for travel to the country (ies) to which I will travel as part of my Study Abroad Program experience and that illness due to failure or refusal to do so is my sole responsibility. I consent to the giving of such medical and/or surgical care as may become necessary for my well being, should the need arise, and I understand that the cost thereof will be my sole responsibility. I agree that I shall be subject to the Clayton State University Student Code of Conduct, supervision and authority of the faculty in charge and to the standards of conduct stipulated by the faculty in charge. I further acknowledge that the supervising faculty has the sole authority to make decisions regarding the continued participation of any individual in the Program whose conduct may necessitate disciplinary action. Any refund of fees shall be in the sole discretion of the University and the University reserves the right to refuse a refund. I authorize the University to communicate in emergencies with the person(s) provided in my application materials. I assume sole responsibility for my safety should I choose to book my own transportation for any part of the Program. Further, I understand that I may elect to travel independently at my own expense before or after the Program or during free time within the time of the Program ( Independent Travel ). I agree to inform a Program supervising faculty member of my Independent Travel plans. However, I assume all involved risk and understand that the University is not responsible for me or my safety during such Independent Travel. The University does not guarantee that Program participants will be able to obtain documentation required for any portion of their Program-related travel. I understand that I am solely responsible for obtaining all documentation necessary for my travel in the Program including, but not limited to, obtaining a passport and any required visas. I further understand that, in the event my citizenship status requires me to obtain a visa or other documentation prior to reentry into the United States after traveling abroad, that I bear the sole risk and responsibility for obtaining such documentation; further, I agree to hold the University harmless if I am unable to obtain such required documentation and, as a result, am denied reentry into the United States. I realize that baggage is carried or conveyed at my own risk and that baggage insurance is strongly recommended. The passenger's contract ticket in use when issued shall constitute the sole contract between the airlines and me. I attest that I have received and am keeping a duplicate copy of this Release, Covenant Not to Sue and Indemnification and agree to be bound by its terms. I give the Universities permission to reproduce and use for educational or promotional purposes any and all photographs, videos, movies, or sound recordings taken of me during my participation in the study abroad experience. IN WITNESS WHEREOF, I have hereunto set my hand this day of, 20. Participant signature DOB Address City, State, Zip Code, Country Parent/Legal Guardian signature if Participant is a minor Page 6 of 7
========================================================================================== TO BE COMPLETED BY PROGRAM DIRECTOR Date and time application received: Date: Time: Is the student in good academic standing at the time of application? Yes No GPA Has the student been given special permission NOT to take the course? Yes No Will the student be 18 years old at the time of departure? Yes No ========================================================================================== Page 7 of 7