SOLES Global! GLOBAL EXCHANGE APPLICATION Program of Application: Full Legal Name:
Birthdate:
Local Address:
Daytime Phone:
City:
State:
Alternate Phone:
Zip:
E-mail address:
Student Number:
Academic Status: (Please circle) Undergraduate
Masters
Doctorate
Emergency Contact:
Non-Credit
Home Phone:
Address:
Work Phone: City:
Are you a US Citizen?
Passport?
Yes
Yes
No
Credit for Other Institution: _____________________________________
State:
If yes, Expiration Date?
Zip:
If non-US, from which country?
No
Where/How did you first hear about SOLES Global!: What previous foreign countries have you visited and for how long (may use back if necessary)?
Note: If you have a disability and require special on-site accommodations, you are strongly encouraged to contact SOLES Global! as soon as possible.
Your signature verifies the following: 1. I have completed the necessary program prerequisites to enroll in this program if necessary (See Undergraduate or Graduate Bulletin) and am in good academic and disciplinary standing at the University of San Diego. 2. I have paid my $50 Global Exchange fee (nonrefundable). 3. I have read, understood and will abide by the Global Education Handbook from SOLES Global!. Applicant Signature:
Date:
This application must be completed and returned to SOLES Global!
University of San Diego, School of Leadership & Education Sciences BA-216, 5998 Alcala Park, San Diego, CA, 92110-2492 ______________________________________________________________________________________1 (619) 260-7443 www.sandiego.edu/soles/solesglobal solesglobal@sandiego.edu
SOLES Global!
ACADEMIC ADVISING FORM Student Before you decide to take a course or semester at another university, it is important that you have thorough academic advising so that you understand how the courses taken overseas will fit into your degree. In many cases, it will not be possible to determine in advance the course equivalences for course work you take overseas. It is therefore imperative that you understand your current standing with respect to the degree requirements. Your semester overseas must be documented by a transcript. You should also save all of your class notes, graded papers, syllabi, your weekly schedule plus any certified documents of attendance provided by the school. You, your academic advisor, and your Program Director must sign this form. Faculty Advisor & Program Director Elective credits are the only credits transferable to USD unless the student has your expressed permission to count credits toward their specialization. In such a case, the student must approach you for your approval. The student should provide you with a description of the course he/she plans to take during the Global Exchange as well as some information about the program/institution he/she is attending. Please review the information and decide whether or not credit should be awarded toward a specialization in your area. If you approve of the request, please sign the form. For each course that can be counted, please sign that area as well. Note that in many cases, the courses will transfer only as pass/fail credits. Student Name:
USD Program:
USD ID#:
Specialization:
Current Phone#:
Current Email:
Credits Needed to Graduate: ___________ as of _______________ (fall, intersession, spring, summer) semester, 200_____. Student’s Signature
Date:
We agree with the Global Exchange Course Approval Record as detailed on the back of this form and support the student in his/her Global Exchange choice. ____________________________ Faculty Advisor’s Name
_________________________________ Faculty Advisor’s Signature
_____________________ Date
____________________________ Program Director’s Name
_________________________________ Program Director’s Signature
_____________________ Date
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SOLES Global! COURSE APPROVAL RECORD Participant Name _____________________________ID Number_____________ Global Exchange Host Institution_______________________________________ Semester and Or Dates Abroad________________________________________ To Be Completed By Student Department and Course Number
Exact Course Title
Course Counts for Specialization or Elective
To Be Completed by Faculty Advisor Number and Number of Type of USD Credits at Semester Host Credits Institution
To Be Completed by Program Director
USD Equivalent
Initial for Approval
Participant Signature_________________________________ Faculty Advisor Signature_____________________________ Program Director Signature____________________________
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SOLES Global! RECOMMENDATION FORM To the recommender: The student named below is giving you this form in order to provide an evaluation of their qualifications for an academic Global Exchange program offered through SOLES Global!. Students must be approved for a Global Exchange on the basis of their academic ability, academic standing, as well as maturity. It is important to the student and USD that we select only those students who are most likely to succeed in and benefit from this program. We appreciate your candid opinion as to the applicant’s qualifications. As you will see below, the applicant has waived right of access to this reference. The student’s application cannot be processed until references are returned. Therefore, we would appreciate receiving your response as soon as possible. Please do not give this form to the applicant but return it directly to the SOLES Global! Center. We thank you for the time you are taking in this matter. To be completed by the student: Name of Student: _______________________________________Phone #: _______________________ Address: ______________________________________________E-mail: _________________________ SOLES Program: ____________________________Specialization: ______________________________ Global Exchange Host Institution: _________________________________________________________ Global Exchange Semester &/or Dates: ____________________________________________________ Name & Title of Reference: ______________________________________________________________ All rights of access conferred by the Family Educational Rights and Privacy Act of 1974 (P.X. 93-380) as amended, or otherwise, to all information and materials of any kind received by the University of San Diego from any source in connection with this application are hereby voluntarily waived. _________________________________________________ Signature of Applicant
________________ Date
This application must be completed and returned to SOLES Global! On-campus Address: SOLES Global! Center, Barcelona-216 Mailing Address: SOLES Global!, School of Leadership and Education Sciences, University of San Diego, 5998 Alcala Park, San Diego, CA, 92110-2492
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SOLES Global! To be completed by the Recommender: 1.
How long and in what capacity have you known the applicant?
2.
If selected, this student will be required to make an adjustment to a challenging living situation. The student’s success at the host institution will be strongly affected by this adjustment of living in a foreign environment. Based on your knowledge of the applicant, please give your opinion of his/her ability to make such adjustments.
Note: If the host institution is in a non-English speaking country, and you have knowledge of the student’s capabilities in the primary language of that country, please answer questions #3. If not, please move on to question #5. 3.
Please indicate your opinion of the applicant’s present ability to converse in the host country’s language. Should have no difficulty Should be able to manage adequately after a short period of adjustment abroad Should take language courses before going and once there
4.
How would describe the applicant in terms of maturity, sense of responsibility, reliability, honesty, and character?
5.
Please use this space to make any additional comments you want to make concerning the applicant’s ability to be successful in the Global Exchange (attach an additional sheet if necessary).
6.
Please check the statement that you feel most accurately reflects your opinion. The student has my strong recommendation. I have minor reservations, such as ____________________________________ __________________________________but am willing to recommend this student. I cannot recommend this student for Global Exchange.
______________________________________________________ Address
_____________________ Phone Number
____________________________________ Signature
________________ Date
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SOLES Global! Mondragon University Exchange Student Housing Plans Form Personal Information Date of Exchange:____________________________
Name: ________________________________________________________________________ Home Address:_____________________________ City________________ Country__________ Postal Code ________Home Telephone:_____________Alternate Phone Number:____________ E-mail Address____________________________________
Housing Plans
Please indicate housing choice: On-campus Apartment (Select one and contact USD Housing Services to reserve space at housing@sandiego.edu or 619-260-4777): San Antonia Missions (SAM) San Antonio de Pauda (SAP) University Terrace Apartments (UTA) Off-campus (Please provide the address of the location): Local San Diego Address:___________________________________ Homestay Services (Please provide agency and placement agency): Name of Agency:__________________________________________ Address of Agency:________________________________________ Telephone Number of Agency:_______________________________ Host Placement Name:______________________________________ Host Placement Address:____________________________________ Host Placement Telephone:__________________________________ Other (Provide description of housing and contact information such as telephone and address:________________________________________________________ I understand that finding and selecting housing is my responsibility.
__________________________________ Student Signature
_____________ Date
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SOLES Global! DS-2019- Page 1 REQUEST FOR FORM DS-2019 FOR USE BY EXCHANGE STUDENTS AT THE UNIVERSITY OF SAN DIEGO When a department at the University of San Diego has invited an international student to participate in an exchange program, the J-1 visa is often the most appropriate visa for the student. This form should be completed by the host department (not by the student), signed by the department head, and sent to the Office of International Services. The Office of International Services will then issue a Form DS-2019, which the student should use to get a J-1 visa and enter the U.S. This request form should not be used for faculty and/or researchers. If there are any questions, please call the Office of International Services at (619) 260-4678. PART L – DEPARTMENT INFORMATION 1. Host Department: School of Leadership and Education Sciences 2. Host Professor/Program Coordinator: Dr. Susan Zgliczynski 3. Phone: 619-260-4287 Email: zglnski@sandiego.edu
PART II – STUDENT INFORMATION 4. Name of student: ________________ ________________ ________________ Family Name First Name Middle Name 5. Date of Birth: __________________________ Country of Birth: ________________ Month/Day/Year 6. Country of Citizenship: ______________________ City of Birth: _______________ 7. Country of legal Permanent Residency: ________________________________ 8. Position in country of permanent residency: _________________________________ _______________________________________________________________________ 9. What evidence do you have that this person has adequate English skills to function as an Exchange Student in your department? ______________________________________ 10. Has this Student held J-1 or J-2 immigration status at any institution in the past 12 months? (Yes/No) If yes, give dates and locations of all visits in last 12 months: ____________________ ______________________________________________________________________ 11. Will the Student be accompanied by spouse or children? (Yes/No) (If yes, give names, dates of birth, places of birth, country of citizenship and relationship to student on separate page) Please note that children can only be considered for J-2 visa status when they are under the age of 21.
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SOLES Global! DS-2019- Page 2 PART III – PROGRAM INFORMATION Description of Student’s proposed program at USD: (Examples: Graduate Business courses, Undergraduate Education Courses). Undergraduate Education Courses 12. Dates of visit at USD: from____________________ to ________________________ Month/Day/Year Month/Day/Year PART IV – FUNDING INFORMATION 13. List all sources of support to student during visit. _______________________________________________________________________ ________________________________________________________________________ IMPORTANT: Provide documentation of any non-USD funding, normally a letter from the funding organization specifying the dates and amount of funding. A letter from the student is not sufficient documentation. Give total amount of funding for visit. SOURCE:_____________________ AMOUNT:____________________________ Student’s government: ______________________________________________ Other organization (s): _________________________________________________ Personal funds (if necessary to supplement other funds only; provide documentation): Attached is USD certificate of finances to be completed by student. PART V – HEALTH INSURANCE INFORMATION 14. Host Department _____will___X__will not (check one) pay for health insurance arranged by USD for international student. 15. Student will enroll in health insurance provided for international students and scholars at USD. (Yes/No) If yes, have student complete and send attached promissory form to the Office of International Services. Fax No. (619) 260-4170. Approval by Department Head, Host Department: I certify that the above information is correct. _____________________________ Signature ______________________________ Printed Name
_______________ Date
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SOLES Global! DS-2019- Page 3 DEPENDENT INFORMATION If exchange student is bringing dependents to the United States, please complete the following information: 1. Last Name: _________________________ First Name: _____________________ Date of Birth: _____________________ Country of Birth: _____________________ Month/Day/Year City of Birth: ____________________ Country of citizenship: __________________ Country of Legal Permanent Residency: ___________________________________ Relationship to Student: _______________________________________________
2. Last Name: ________________________ First Name: ________________________ Date of Birth: ______________________ Country of Birth: _____________________ Month/Day/Year City of Birth: _______________________ Country of Citizenship________________ Country of Legal Permanent Residency: _____________________________________ Relationship to Student: __________________________________________________
3. Last Name: __________________________First Name: _______________________ Date of Birth: ______________________Country of Birth: _______________________ Month/Day/Year City of Birth: _____________________ Country of Citizenship: ___________________ Country of Legal Permanent Residency: _______________________________________ Relationship to Student: __________________________________________________
4. Last Name: _____________________ First Name: ___________________________ Date of Birth: ___________________ Country of Birth: __________________________ Month/Day/Year City of Birth: ____________________ Country of Citizenship: ____________________ Country of Legal Permanent Residency: _______________________________________ Relationship to Student: __________________________________________________
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SOLES Global! DS-2019- Page 4
HEALTH INSURANCE PROMISSARY NOTE FOR J-1 EXCHANGE VISITORS PROGRAM Exchange visitors, professors, research scholars, and students who do not obtain their own health insurance before arriving at the University of San Diego should have the funds available to purchase it from the University, for themselves and for their dependents, no later than the day they arrive on campus.
I, _________________________ _________________________ , Last Name
First Name
will purchase health insurance coverage from the University of San Diego no later than the day I arrive on campus. I understand that if I willfully fail to carry health insurance for my dependents or myself, my J-1 sponsor must terminate my program and report the termination to the U.S. Department of State.
DEPENDENT INFORMATION: LAST NAME FIRST NAME AGE
J-1’s Signature
RELATIONSHIP TO J-1
Date
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SOLES Global! DS-2019- Page 5 UNIVERSITY OF SAN DIEGO
DECLARATION OF FINANCES A requirement of your admission or participation in research activities is to show that sufficient funds are available to specifically cover the expenses of the first year and subsequent years of study. This form must be completed by international applicants and returned to the Office of International Services. You may use this form in providing the necessary information or you may substitute an official letter of financial certification. These documents must be specifically addressed to the University of San Diego. The financial information must be dated within three months of the date of your application and must provide current financial information.
APPLICANT INFORMATION: Please type of print in ink. Name: _____________________________________________________________ Last name First Name Certification by applicant: This is to certify that the financial information furnished on this form or by a separate letter by me is true and complete to the best of my knowledge.
Signature: ___________________________
Date: _______________
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SOLES Global! Participant Health Information This form must be completed and signed by all study abroad participants and, if applicable, by her/his treating physician or clinician. It must be returned to the SOLES Global! Office in Barcelona 216 as part of the application packet no later than the application deadline. The information requested will allow USD to better assist the participant should health concerns arise during the study abroad experience, and particularly in the event of a health emergency. Because even mild, pre-existing health disorders can become serious under the stresses of life while studying overseas, it is important that a healthcare provider evaluate those conditions which might limit the participant’s ability to successfully undertake the study abroad program. Limited medical resources abroad must be taken into consideration. USD will make reasonable accommodations for the students needs in order to ensure that suitable accommodations and care is available. However, some destinations and/or types of programs may not be advisable for individuals with certain health conditions. The information provided below may be shared with on-site program staff. The participant should complete Parts 1-6; the participant’s health care provider must complete Part 7 (if applicable). 1) Student Information Participant: ______________________________ Program: _________________________Term:__________ 2) Emergency Contact Information Emergency family contact 1: _____________________________ Relation to participant: ___________________ Address: ___________________________________ City: ________________State: ________ Zip:__________ Phone (daytime): ___________________ (evening): ______________________ (cell): _____________________ Email address: __________________________________________________________ Emergency family contact 2: ______________________________ Relation to participant: __________________ Address: _____________________________________ City: _______________State: _______ Zip:__________ Phone (daytime): ___________________ (evening): _______________________ (cell): ____________________ Email address: __________________________________________________________
Health care provider (personal physician, group practice, etc.): ________________________________________________ Office phone number: _________________________ Emergency phone number: _________________________ Health care provider (personal physician, group practice, etc.): ________________________________________________ Office phone number: _________________________ Emergency phone number: _________________________ 3) The participant must be covered by health (“sickness and accident”) insurance while attending a USD Study Abroad Program. It is important for the participant to know the terms of coverage and reimbursement of the USD-required coverage through CISI and determine whether CISI is sufficient for her/his condition. If the CISI coverage is not adequate to meet the student’s needs or if a pre-existing condition is not covered, it is the student’s responsibility to obtain additional coverage. Participant’s additional insurance provider, policy number and phone number: __________________________________________________________________________________________
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SOLES Global! PARTICIPANT:____________________________________ STUDENT NUMBER:_______________ 4) Personal Medical History Have you ever had: 1. fainting, dizzy spells, or a seizure disorder? 2. heart trouble, murmur, chest pain or blood pressure problem? 3. asthma, chronic cough, shortness of breath or tuberculosis? 4. stomach or intestinal sickness (ulcers, stomach, gall bladder or intestinal)? 5. a hernia? 6. liver, kidney or bladder problem? 7. an eye, ear or nose condition or injuries or difficulty with vision or hearing? 8. skin disorders (rashes or skin allergies)? 9. broken bones 10. neck, spine or back trouble? 11. chronic conditions such as anemia, diabetes, thyroid problems? 12. a surgical operation or been advised to have one? 13. mental health treatment in a hospital or other institution? 14. accidents or injuries?
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
No No No No No No No No No No No No No No
15. Are you currently under a doctor’s care? Yes No If yes, please explain: ___________________________________________________________ 16. Are you currently taking medication? Yes No If yes, please list: ______________________________________________________________ 17. Have you ever had an allergic reaction to any drug? Yes No If yes, please explain: ___________________________________________________________ 18. Have you ever had a serious allergic reaction to bee stings, or other substances? Yes No If yes, please explain: ___________________________________________________________ 19. Have you ever been treated for tuberculosis? Yes No Date of last TB test: _________________________ Results: ___________________ 20. Date of last tetanus shot: ______________________
Blood type, if known: ________
If the answer is “yes” to any of the above, please use the space below to write an explanation for each item. Describe the illness, injury, or condition including date(s) when it occurred, and the treatment received. If there is additional information you think may be helpful in provision of your health care while you are abroad, please comment. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _____________________________________________________________________________________________ _______________________________________________________________________________________
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SOLES Global! PARTICIPANT:____________________________________ STUDENT NUMBER:_______________ 5) Family Medical History: Have any close relative had any of the following conditions? If yes, please identify relationship (parent, sibling, uncle, grandmother, etc.) and their present age or age at death. Heart Disease ____________
High Blood Pressure ______________ Stroke _____________
Kidney Disease ____________
Cancer
Tuberculosis
Diabetes
____________
______________
Asthma_____________
______________
6) The participant is required to answer questions a through d below, by placing their initials in the appropriate No/Yes spaces and attaching additional pages as needed; consider and respond appropriately to 4e. All responses are requested for the sole purpose of assisting program staff in meeting emergencies and any special health needs. a. No ___ Yes ___ Will you require special accommodations or support services while abroad because of a disability (learning, visual, hearing, mobility, psychiatric) or other impairment? If yes, please provide verification of the disability from the Office of Services for Students with Disabilities, as well as a full description of what arrangements may be needed. b. No ___ Yes ___ Do you have any drug, food, or other allergies? If yes, the student is responsible having applicable documentation and the recommended emergency treatment plans in their possession throughout the program period. c. No ___ Yes ___ Do you have any health related dietary restrictions? If yes, the student is responsible for notifying the host family, for monitoring their own dietary intake, and for having recommended emergency treatment plans in their possession throughout the program period. d. No ___ Yes ___ Do you regularly take medications or wear corrective lenses? If yes, the student is responsible for taking an adequate supply of each medication, in pharmacy-labeled containers, copies of the prescription and the prescription for replacement eye glasses or contact lenses. NOTE: The International SOS Emergency Assistance Program provides a mechanism for the student to record the above information and to scan personal documents, such as prescriptions. Utilization of this tool is highly recommended.
e. No ___ Yes ___ Do you have or have you experienced a health related condition which may impede your ability to complete the Study Abroad program, a medical clearance from your treating physician is required prior to final approval for your participation. Applicable conditions include but may not be limited to: •
Chronic physical disorders
•
Current or Prior Mental Health Treatment
•
Physical limitations or restrictions
If yes, the student is required to review the parameters of the requested Study Abroad Program with the treating healthcare provider(s) and have them complete and sign section 7. All responses that I have given on this form and attached sheets are true and accurate to the best of my knowledge. I understand that failure to supply true and accurate information may result in my dismissal from the program. I will provide the USD Study Abroad Programs Office with the necessary clearance to participate if 4e applies to me. I will notify the USD Study Abroad Programs Office of any relevant changes in my health that occur prior to the start of the program, and that may affect my ability to participate. ___________________________________________________ Signature of participant affirming above statements
____________ Date
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SOLES Global! PARTICIPANT:____________________________________ STUDENT NUMBER:_______________
The participant should complete Parts 1-6. If the answer to 6e is “Yes” then the participant’s health care provider must complete Part 7 below. 7) Health Care Provider: The individual presenting this form for your review and signature is requesting participation in a Study Abroad Program. S/he has or has experienced a health related condition (see 6e), which may put her/him at higher risk while studying abroad. You are asked to evaluate the individual’s health status and respond below as appropriate. Please take into account that living and studying in a foreign environment frequently triggers unexpected physical and emotional stress, which can exacerbate otherwise mild disorders. It is important that the participant be able to adjust to potentially dramatic changes in climate, diet, living arrangements, social life, and study demands that may seriously disrupt accustomed patterns of behavior. Furthermore, while healthcare in many places is readily available and of sufficiently high quality, the participant may be going to a location where treatment is difficult to obtain and/or less reliable. The participant often will not have convenient, if any, access to the kinds of resources and support on which s/he may be dependent in the United States. On the basis of my knowledge of this student’s health and her/his program of choice, I (please check response that applies)… find no medical or psychological contraindications to her/his participation in this study abroad program. recommend against this individual participating in this or any study abroad program. support this individual participating in this study abroad program, but only under the following conditions: I have discussed my response above with the participant and have given appropriate counseling. __________________________________________
____________________
Signature of health care provider affirming responses in 7) above
Phone number
_________________________________________
____________
Printed name of health care provider
Date
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SOLES Global! PARTICIPANT:____________________________________ STUDENT NUMBER:_______________ AGREEMENT AND RELEASE USD -- Foreign Programs I, the undersigned (the "Participant"), am an applicant for an educational study abroad program or other program outside the United States including but not limited to experiential learning/volunteer programs (the "Program") arranged by the University of San Diego (hereinafter the University of San Diego, its officers, teachers, trustees, agents and employees are collectively referred to as "USD"). Under some circumstances, I may opt to stay with a host family (the "Host Family") while I am abroad. Under other circumstances, I may choose to live in a dormitory or other type of residence. I understand that, as a condition of permitting me to attend the Program, USD requires me to agree to the following: 1.
Personal Property. I understand that neither USD nor the Program, nor the Host Family, nor the landlord, is responsible for my personal property. I understand that I am solely responsible for any lost, damaged or stolen property. Insurance. I understand that USD does not provide health, liability, property or other insurance for me. a. I understand that neither USD, nor the Program, nor the Host Family, nor the landlord, if applicable, is responsible for any medical expenses incurred by me while participating in the Program. I understand that I should obtain medical insurance coverage for the term of my participation in the Program, and that in most cases, I will be required to show proof of medical insurance in order to obtain my student visa. b. I understand that optional personal insurance is made available to me and I acknowledge receipt of information pertaining to the optional personal insurance. c. I understand that neither USD, nor the Program, nor the Host Family, nor the landlord, if applicable, is responsible for any property damaged or destroyed by me or for any liability which results from my activities while participating in the Program. I am responsible for any damage or destruction of property or any injury to any person which I inflict or cause while participating in the Program. 2.
Release of Liability. I hereby release USD, and the Program, the Host Family, and the landlord ("Releasees"), if applicable, and each of them from, and agree not to sue, such persons and entities for any claims arising from, or in connection with, any physical, emotional or mental injury or property damage that I may suffer from any cause whatsoever, including without limitation such injury or damage resulting from the Program, acts of God, strikes, government regulations and restrictions, terrorist activities, delays, weather, or the acts, omissions or errors of USD or any agent of USD. I understand that neither USD, nor the Program, has undertaken any duty to investigate the Host Family as a condition to participate in the Program, and I thereby release USD and the Program from, and agree not to sue USD or the Program for, any claims that arising from, or in connection with, any physical, emotional, or mental injury or property damage that I may suffer for any cause whatsoever arising out of or resulting from the acts or omissions of my Host Family, if applicable, or any member of my Host Family. I hereby agree that the release of claims set forth in this paragraph shall apply to claims that have not yet accrued based on potentially unforeseeable future events and circumstances, and I hereby waive the provisions of, and relinquish any rights under, California Civil Code Section 1542 which states: "A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor."
SOLES Global! PARTICIPANT:____________________________________ STUDENT NUMBER:_______________ 3.
Unsupervised Activities. I understand that USD, the Program, the Host Family, or the landlord, if applicable, shall not have any responsibility to or for me when I am absent from activities in the Program, while I am enrolled in the Program, such as to visit friends or relatives. Some programs may not accept early arrival, and housing accommodations are contracted for the duration of the Program only. Neither USD, nor the Program, nor the Host Family, nor the landlord, if applicable, assume responsibility for me during stay-ahead or stay-behind periods.
4.
Rules and Directions. I understand, am familiar with and agree to abide by USD rules upon acceptance to the Program. I also agree to abide by the rules and directions of my Program, my Host Family, if applicable, or other residence, or USD personnel during my participation in the Program. I understand that failure to do so may result in USD or the Program terminating my participation in the Program. I understand that to disobey such rules or directions is to waive the right to a refund of any part of my Program fee, and that I may then be sent home at my own expense.
5.
Medical Authorization/Illness. I understand that neither USD, nor the Program, nor the Host Family, nor the landlord, if applicable, can be held responsible for my health, safety, or well-being during the Program. If I become ill or incapacitated, USD, the Program, the Host Family, or the landlord, if applicable, may take any action deemed necessary for my safety and well-being, including securing medical treatment, at my own expense and transporting me home at my own expense. I understand that the quality of medical care in a foreign country may differ from the quality of medical care available in the United States, and I knowingly and voluntarily assume all risks associated with this fact. I understand and agree that any physician, dentist, or other health care professional to whom USD or my Host Family may refer me for medical emergencies or other treatment is not an agent of USD or my Host Family. I understand and agree that neither USD nor my Host Family shall be liable in any way for any error, act, or omission of any physician, dentist, or other health care professional, hospital, or other medical facility that may evaluate, diagnose, or treat me during the Program.
6.
Indemnification. I hereby agree to defend, save, indemnify and keep harmless USD against any and all liability, claims, judgments, or demands for financial liability or obligation, property damage and/or bodily injury which I incur, or to others which I cause, except claims or litigation arising through the sole negligence or willful misconduct of USD.
7.
Changes to Program. I understand that USD and the Program have the right to make changes in my Program itineraries and departure dates. The Program has the right to modify possible group transportation arrangements, including the use of substitute airlines.
8.
Changes to Housing and Miscellaneous Fees. I understand that USD and the Program have the right to adjust their published fees when the dollar fluctuates in value.
9.
Travel Documentation. I understand that it is my responsibility to secure travel documents (passport, visa, inoculations and other aspects of international travel) if required.
10.
Photograph Consent. I understand that any likeness taken of me while participating in the Program and any comments or statements I make related to the Program may be used by USD in future materials published by USD with no compensation payable to me.
11.
Effective Date. I understand and agree that this AGREEMENT AND RELEASE shall be effective upon receipt of this waiver by USD and my acceptance by USD as a participant in the Program.
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SOLES Global! PARTICIPANT:____________________________________ STUDENT NUMBER:_______________ 12.
Cancellation. I understand that USD may cancel my Program and that the Program may cancel any course associated therewith at any time and for any reason. I understand that if I wish to cancel my reservation in the Program, I must do so in writing to the director of my Program at USD on or before the date designated by USD as the last date for cancellation. I understand that each of the Programs covered by this Agreement also sets its own withdrawal and refund policy, and that I may forfeit my confirmation deposit, housing fee, or other fees according to each policy.
13.
Limitation of Liability. In the event that the releases provided in this AGREEMENT AND RELEASE are found to be unenforceable, in whole or in part, and USD is held liable for any reason in connection with my participation in the Program, I understand and agree that USD's liability to me shall be limited to the types and amounts of coverage actually afforded to USD under its liability insurance policy.
14.
Entire Agreement. I understand that this Agreement constitutes the entire agreement between USD and me with reference to the subject matter referenced to herein. This agreement may be amended or modified only in writing.
15.
Governing Law/Arbitration. I understand that this Agreement shall be governed in all respects, and performance hereunder shall be judged, by the laws of the State of California. Any and all claims or disputes between I and USD arising out of or relating to this AGREEMENT AND RELEASE shall be submitted to binding arbitration before the American Arbitration Association, San Diego Office, according to the rules then in effect.
16.
Read and Understand. I understand that my signature below certifies that I have read fully this AGREEMENT AND RELEASE, understand its contents, and agree to be bound by all terms and conditions stated herein.
I acknowledge that I am voluntarily executing this Agreement of my own free will. After having the opportunity to consult with legal counsel of my own choosing, I understand that this release means I am giving up, among other things, rights to sue USD and its Releases for injuries, damages, or losses I might incur. I also understand that this release binds my heirs, executors, administrators, and assigns, as well as myself. I further acknowledge and understand that this Agreement will absolve USD and its Releasees from any liability in connection with any injury or harm suffered as a result of my participation in the Program. I acknowledge that I have been made aware of any and all risks of participation in the Program. THIS IS A RELEASE OF LEGAL RIGHTS. READ BEFORE SIGNING. Participant Name (please print): Participant Signature:
Date:
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