Travel Abroad Spring 2014 TA Form 6 (Page 1 of 1) North Campus Kendall Campus Wolfson Campus West Campus Medical

Center Campus Homestead Campus InterAmerican Campus Hialeah Campus

Emergency Contact Information

This document and its contents constitute a student record and are exempt from public records under 1002.22 and 1006.52, Florida Statutes. The contents of this document can only be disclosed in accordance with the Students and/or Parent(s)/Guardians consent. STUDENT NAME STUDENT NUMBER _____________________________ ___________________________________ Address: _____________________________________________________________________________ _____________________________________________________________________________ E-Mail: ______________________________ Home Phone: _________________________ Mobile Phone: _________________________

Emergency Contact
Name: ___________________________ Relationship: _________________ Home Phone: ________________ Address:

_____________________________________________________________________________ E-Mail: __________________________ Alternate Phone: ________________________________ *Health Insurance Provider: ___________________________________________________________________________ Policy No. _____________________________________ Phone: ______________________ I hereby certify that all of the above information given is true and accurate. I hereby consent to Maria Mari, Georgina Hart, Jose Orta or Franklin Aviles disclosing this information for the sole purpose of assessing my/students medical needs or obtaining medical services on my/students behalf. ___________________________________ Students Signature Date __________________________________ Parent(s)/Guardians Signature Date Required for students under 18 years of age *This information shall be only disclosed to a healthcare facility should student require medical services and is unable to personally convey this information to the medical service provider.

Travel Abroad Spring 2014 TA Form 5 (Page 1 of 2) North Campus Kendall Campus Wolfson Campus West Campus Medical Center Campus Homestead Campus InterAmerican Campus Hialeah Campus

Permission for Emergency Treatment

This document and its contents constitute a student record and are exempt from public records under 1002.22 and 1006.52, Florida Statutes. The contents of this document can only be disclosed in accordance with the Students and/or Parent(s)/Guardians consent. STUDENT NAME STUDENT NUMBER

_________________________

_______________________

I certify that I am over 18 years of age and am responsible for my own welfare. As indicated and signed above, I authorize the program director abroad and/or physician-in-charge to make the decision cooperate in case of medical emergency. I authorize the physician in charge to decide on appropriate medical treatment in any medical emergency. I hereby consent to Maria Mari, Georgina Hart, Jose Orta, or Franklin Aviles disclosing any and all of my medical information in their possession for the sole purpose of assessing my medical needs or obtaining medical services on my behalf. Students Signature: _________________________________ Date: _____________________________

FOR PARENT(S) GUARDIANS OF STUDENTS

I/We hereby authorize Maria Mari, Georgina Hart, Jose Orta, and Franklin Aviles to obtain and authorize medical treatment as is necessary to protect the wellbeing of my child, including authorization for emergency treatment, anesthesia, and/or surgery as deemed necessary. Further, I/We do hereby release and agree to hold harmless Maria Mari, Georgina Hart, Jose Orta, Franklin Aviles, Miami Dade College its, Board of Trustees, directors, officers, employees and agents from any and all claims which may arise from said medical treatment. I/We hereby consent to any of the above mentioned individuals disclosing any and all of the students medical information in its position for the sole purpose of assessing the students medical needs or obtaining medical services on the students behalf.

_________________________________ Students Signature Date

____________________________________ Signature of Parent/Guardian Date

Permission for Emergency Treatment Page 1

TA Form 5 (Page 2 of 2)
Note: On rare occasions an emergency requiring hospitalization, surgery, and/or other medical treatment develops. Since in some countries/states student under the age of 21 might not be administered an anesthetic or operated on without the written consent of the parent or guardian, we request that the parent or guardian sign this document in order to prevent a dangerous delay in the administration of emergency medical attention.

The following request information shall be only disclosed to a healthcare provider should student require medical services and is unable to personally convey this information to the medical service provider. Insurance Information Name and address of students medical insurance company valid in USA.

Policy No. __________________________________________________________ Emergency Medical Information Do you suffer from any of the following conditions? ___ Allergies ___ Asthma ____ Convulsion _____ Heart Trouble ___ Diabetes ___ Fainting Spells ____ Bleeding Disorders ___ Other (explain) Do you wear? ___ Contact Lenses ____ Dentures Are you currently taking any medications? (Please list) __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________

Permission for Emergency Treatment

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Travel Abroad Spring 2014

TA Form 4 (Page 1 of 2) PHYSICIAN STATEMENT

Program: _______________________ Country: _______________________ Beginning Date: _________________ Ending Date: ____________________

This document and its contents constitute a student record and are exempt from public records under 1002.22 and 1006.52, Florida Statutes. The contents of this document can only be disclosed in accordance with the Students and/or Parent(s)/Guardians consent.

I have examined ____________________________________________ and believe that he/she is physically fit and medically qualified to participate in an overseas study program. He/She presents no evidence of communicable diseases or over-fatigue or any other medical condition that would affect the quality of his/her academic performance or pose a medical danger to himself/herself or others while studying abroad. His/Her personal health records are as follows: (Physician please take into consideration evidence of instability, headaches, allergy, insomnia, diabetes, depression, asthma, etc.) DISEASE, OPERATION, INJURY PERIODS OF DISABILITY __________________________________________________from_______________________________ __________________________________________________from_______________________________ __________________________________________________from_______________________________ __________________________________________________from_______________________________

ADDITIONAL COMMENTS:

Travel Abroad Program Physicians Statement

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TA Form 4 (Page 2 of 2) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

In my judgment, the candidate is not likely to need medical or surgical attention during the proposed period of Travel Abroad as the result of disease, operation or injury heretofore experienced. Date: ____________________ Signature: _________________________________________ Name (please print) _________________________________ Address: __________________________________________ __________________________________________ Telephone: ________________________________________ CONSENT TO LIMITED DISCLOSURE: I hereby consent to Maria Mari and/or Georgina Hart, Jose Orta, and Franklin Aviles disclosing this information for the sole purpose of assessing my/students medical needs or obtaining medical services on my/students behalf. _______________________________________________________________________________ Students Signature Required for students under 18 years of age: ________________________________________________________________________________ Parent(s)/Guardians Signature Date Date

________________________________________________________________________________ Parent(s)/Guardians Signature Date

Travel Abroad Program Physicians Statement

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Travel Abroad Spring 2014

TA Form 3 (Page 1 of 3)

TRAVEL ABROAD PROGRAM RELEASE

I, the undersigned, an applicant for admission to a Paris-London-Dublin Travel Abroad program (the Program), do waive and release any and all claims, demands or causes of action against Maria Mari, Georgina Hart, Jose Orta, Franklin Aviles (faculty chaperones together referenced as the Group), the Miami Dade College, its District Board of Trustees, employees and agents (together referenced as the College) or its host institution(s) abroad for any injury, accident, damages and/or death caused by vehicles, act of war, weather, strike, sickness, quarantine, terrorist activity, government vehicles restriction or regulation or stemming from any act or omission of any airline, railroad, hotel, bus company, taxi service, school, college, institute, university, or other firm, and any government or private company or individual. I also release the Group and the College and agree to indemnify them with regard to any financial obligations and/or liabilities that I may incur personally or any damage resulting from my participation in the Program. I understand and acknowledge that I am solely responsible for satisfying such financial obligations and/or liabilities. Accordingly, I waive and release all claims, demands or causes of action against the Group and the College, host institution(s) or other facilities here and abroad, for any injury, loss, damage, accident, delay, or expense resulting from the use of any vehicle, any strikes, weather, sickness, quarantine, service, hotel, restaurant, school, college, or other firm, facility, company or individual, or any other unintended consequences. I accept full financial responsibility for any and all direct expenses incurred from my participation in the Program, including any and all program and instructional costs, including fees, tuition, room and board, travel, insurance and other such costs owed either to the Group, the College, and/or the host institution abroad, and/or any other agent providing services to me as a participant in the Program. If I am the beneficiary of financial aid from any source, I understand that my personal financial responsibility supersedes the expectation or actuality of any disbursement of said financial aid to me and that ultimately I am fully responsible for payment of the items described in this Release. I understand that all travel involves risk. I hereby agree to assume such risk that is inherently part of foreign travel as a condition of my acceptance and participation in the Program. I hereby waive and release any and all claims against the College, and specifically the Group, for any injuries, accidents, damages, losses and/or death incurred in connection with terrorist activities, social or labor unrest, acts of war, mechanical or construction difficulties, diseases, local laws, climatic conditions, abnormal conditions or developments, or any other actions, omissions or conditions outside the Groups or Colleges control. By my participation in the Program I voluntarily assume all risks involved in such travel and presence abroad, whether expected, or unexpected. I hereby acknowledge that I have been warned of such risks, and that I have been advised to take appropriate action and to govern myself accordingly. I am also aware that certain insurance companies do offer insurance against some or many of the perils noted, and that I may insure myself should I so choose.

Travel Abroad Program Release for: ______________________________ ______________________________ ____________ Applicants Initials

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TA Form 3 (Page 2 of 3)
I hereby grant the Group full authority to take whatever actions they deem necessary concerning my health and I fully release the Group and the College from any liability for such decisions or actions as may be taken in connection with my health. I hereby consent to the Group disclosing any and all of my medical information in its possession for the sole purpose of assessing my medical needs or obtaining medical services on my behalf. I authorize the Group, at their discretion, to place me in a hospital within or outside of the United States of America (U.S.) for medical services and/or treatment at my own or my parents/parents/guardians, expense without further consent. If no hospital is readily available and I require medical services, I authorize the Group to place me in the hands of a local physician for treatment. If deemed necessary or desirable by the Group, I authorize the Group to transport me back to the U.S. by commercial airline or other accessible conveyance. I am, or my parents/parents/ guardians are, solely responsible for the expenses associated with such activities. Either my parent(s)/guardian or I will reimburse any funds advanced to me for any purpose upon demand. I have been advised that I must be covered by adequate health and accident insurance, valid in and outside the U.S., during the entire period of my participation in the Program. I agree to comply fully with the rules of the College, the Group and its host institution(s) abroad, and/or travel entities/companies. I agree that the Group has the right to terminate my participation in the Program with no refund of monies paid. In the event of termination, I agree to be sent home at my parents/parents/guardians or my own expense. I understand that the Program is an organized group study program and that group standards must be observed. Except for those periods designated as free time, I will at all time remain under the supervision of the Group or host institution(s) and I will comply with the rules, standards, and instructions for student behavior. I hereby waive and release any and all claims against the Group and the College arising out of my failure to remain under such supervision or to comply with rules, standards and instructions. I agree that the Group, host institution(s), travel facilitators, etc., have the right to terminate my participation in the Program at any time for my failure to abide by the Program standards or for any actions or conduct that the Group or host institution(s) deem inappropriate and incompatible with the interest, harmony, comfort and welfare of other Program participants. I also understand that I am required to abide by any and all local and international laws applicable to me during my participation in the Program. Should I choose to violate those laws, neither the Group nor the host institution is legally obligated to assist me with any civil or criminal allegations or charges against me. I also understand that the Group and its host institution(s) are not responsible for any injury, damage, loss and/or death whatsoever suffered by me during periods of independent (any activity that is arranged by me and is separate from the Program and the Group or during any absence from the Program or other supervised activities) trouble, which I further understand are at my own expense. On group tours or other activities arranged by the Group and/or the host institution(s) I will accept the will of the majority of the Program participants whenever a matter of choices is presented to the group. I understand that from time to time the Group publicity material or that of its host institution(s) may include statements made by its students and/or their photograph and I consent to such use of my comments and photographic likeness. I understand that the Group reserves the right to make changes, including but not limited to: initial campus assignments, academic centers, and alterations in programs, itineraries, schedules and academic calendars as may be required. I understand the Program charges and expenses are based on applicable tariffs, international currency fluctuations, and government regulations and are subject to change depending on conditions and situations at the time of departure. All references in this Release to the College shall also include the Colleges chaperones, group leaders, faculty members, administrators, advisors, hosts, and all other institution personnel. All references to the parent(s) of the applicant shall include the legal guardian and/or any adult legally responsible for the applicant/participant.

Travel Abroad Program Release for: ______________________________ ______________________________ ____________ Applicants Initials

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TA Form 3 (Page 3 of 3)
I possess and understand the terms and conditions set forth in the Groups descriptive information of the Program and I agree that these constitute a part of my agreement with the Group. I understand and agree to all of the Groups terms and conditions set forth in this Release form. I further understand that this Release shall take effect only upon my acceptance into the Program by Maria Mari and Georgina Hart. Signature of applicant: ______________________________ Date: _________________________________ Name (Please Print): ________________________________ I certify that I am the parent or guardian of the above-signed applicant, and that I have read this Release in its entirety and examined the information in the Program description. I hereby join in each part of the Release including such parts as may subject me to personal financial responsibility and hereby relinquish any claim(s) I may have against the Group and the College, as identified in this Release and set forth above, both in my own behalf and in my capacity as legal representative (as applicable) of the applicant, including without limitations any claims arising as a result of the applicants leaving the supervision of the Group or host institution(s) while in the U.S. and abroad. Signature of parent/guardian ____________________________ Date: _________________________________ Name (Please print) ___________________________________ Notary (for signature of parent/guardian)

Travel Abroad Program Release for: Page 3 ___________________________ ___________________________ _________________ Applicants Initials

Travel Abroad Spring 2014

TA Form 1 (Page 1 of 3)

RELEASE AND INDEMNITY AGREEMENT

I, the undersigned, desire to participate in Travel Abroad Spring 2014 (the Program). I understand that the Group (collectively referring to Maria Mari, Georgina Hart, Jose Orta, and Franklin Aviles) will not allow me to participate in the Program unless I also enter into this Agreement. Therefore, in exchange for permission to participate, I make the following representations and agreements, which I understand that the Group is relying on: 1. I am of sound mind, in good health, and have no physical or mental conditions that would hinder or prevent me from participating in the Program. 2. I am at least 18 years of age and I possess the legal capacity to enter into this Agreement. 3. The term the College as used in this Agreement shall mean Miami Dade College, its District Board of Trustees, officers, directors, employees, agents, staff members, campus directors, chaperones, group leaders and advisors, and any host institution(s) faculty abroad and its employees and agents and any tour organizers or arranger employee or utilized in connection with the Program and its employees and agents. The term the Group as used in this Agreement shall mean Maria Mari, Georgina Hart, Jose Orta, and Franklin Aviles. 4. No one associated with the College, the Group, or with the Program has made any representation or promise to me about the matters covered in this Agreement, apart from what is written in this Agreement. Accordingly, this document contains the entire agreement between the Group and me with respect to the matters covered by the Agreement. I understand that the terms and conditions of this Agreement are contractual and legally binding. 5. I understand and agree that this Agreement is intended to provide as much protection to the Group and the College as the laws of the State of Florida permit. If any part of this Agreement is illegal, I still agree to be bound by the remaining lawful provisions of this Agreement. 6. I understand and agree that the laws of the State of Florida will control and will be used to interpret this Agreement. The laws of the State of Florida will govern any legal action arising out of my participation in the Program. I further agree that any legal actions arising out of this Agreement must be filed in a court of jurisdiction in Miami-Dade County, Florida. 7. I understand that this agreement is binding not only on the Group, the College and me but also on our respective representatives, heirs, estates, beneficiaries, successors and assigns.

RELEASE AND INDEMNITY PROVISIONS FOR BENEFIT OF COLLEGE AND CHAPERONES

I understand that all travel, whether it is domestic or foreign, involves risk and can be dangerous. My participation in the Program, I voluntarily expose myself to these risks and dangers, whether expected or unexpected. I am aware of these risks and dangers and I am aware that I may obtain appropriate insurance coverage at my own expense. On my behalf and on behalf of anyone who, as a result of my participation in this Program, can make a claim, I release, discharge and hold the College, the Group, the Groups representatives, heirs, estates, beneficiaries, successors and assigns harmless from any and all liability and responsibility for any loss, damage or injury of any kind, including death, which I may suffer as a result of or in connection with my participation in the Program. This release covers any loss, damage, injury or death caused by:

Release and Indemnity Agreement for: ______________________________ ______________________________ ____________________ Participants Initials

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TA Form 1 (Page 2 of 3)

(1) Any criminal, illegal or unauthorized acts of third parties including but not limited to any terrorist act, hijacking or sabotage; (2) Any social or labor unrest; (3) Any political conditions; (4) Any mechanical or constructional difficulties or conditions; (5) Any diseases, local laws or climatic conditions; (6) Any conditions, development, actions or omissions outside of the control of the Group; and (7) Any other expected or unexpected conditions, developments or risks connected with domestic and/or foreign travel even if I suffer the loss of money, property, health, or life, and irrespective of who is or may be at fault, or whose negligence, including the negligence of the Groups, may have caused my loss, injury or death.

I HAVE READ EACH AND EVERY WORD IN THIS RELEASE AND INDEMNITY AGREEMENT. I FULLY UNDERSTAND ALL OF THE TERMS AND CONDITIONS OF THIS AGREEMENT AND THEIR SIGNIFICANCE. I VOLUNTARILY SIGNED THIS RELEASE AND INDEMNITY AGREEMENT.

NAME OF PARTICIPANT (PLEASE PRINT) _______________________________________ AGE _______ DATE: ___________________________ ADDRESS: ___________________________________________________________________ _____________________________________________________________________________ TELEPHONE: ________________________________ PROGRAM AND DATES (TERM): ________________________________________________ PARTICIPANTS SIGNATURE: _________________________ _________________________

Release and Indemnity Agreement for: ______________________________ ______________________________ ____________________ Participants Initials

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TA Form 1 (Page 3 of 3) Optional

ALL MARRIED PARTICIPANTS MUST HAVE THE FOLLOWING PROVISIONS SIGNED BY THEIR SPOUSE
As a spouse of _________________________________, I have read each and every word of this Agreement and I fully understand the terms and conditions for my spouse to participate in this Program. In exchange for my mutual agreement with my spouse for their participation in the Paris-London-Dublin Travel Abroad Program, I voluntarily sign this Release and Indemnity Agreement. By signing, I agree to release, waive and hold Maria Mari, Georgina Hart, Jose Orta, Franklin Aviles, their representatives, heirs, estates, beneficiaries, successors and assigns harmless from any and all claims I may have, including any claims for loss or deprivation of my spouses services, support, sexual relations, comfort or attention that I may suffer as a result of, arising out of or in connection with any of the events, conditions or risks stated in the Agreement, even if such loss, liability, damage, costs or death is based on the negligence of the Group.

SPOUSES NAME: _____________________________________________________________ AGE: ______________________ DATE: _______________________________________ NAME OF PARTICIPANT (Please print) ____________________________________________ ADDRESS: ____________________________________________________________________ ____________________________________________________________________ TELEPHONE: ___________________________________ NAME OF PROGRAM AND DATES (TERM): ______________________________________ ______________________________________________________________________________ Spouses Signature: ___________________________________

Release and Indemnity Agreement for: ______________________________ ______________________________ ____________________ Participants Initials

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TA Form 2 (Page 1 of 1)
INTERNATIONAL EDUCATION ABROAD PLEDGE OF GOOD BEHAVIOR

As a condition for participation in the Paris-London-Dublin Travel Abroad Program, students must obey all local laws and rules as well as respect local customs. Maria Mari, Georgina Hart, Jose Orta and Franklin Aviles (collectively referred to as the Group) reserve the right to withdraw any student for reasons of offensive personal behavior or inadequate contribution to the academic and educational purposes of this program. INVIOLABLE RULES 1. 2. 3. 4. Students shall attend all briefing sessions, and lectures and participate in all program related excursions. Misbehavior or inappropriate or offensive conduct will result in dismissal from the program and return to Miami at students own expense. Drugs, other than those medically prescribed, are not tolerated, even if tolerated and/or condoned locally. The Group will reserve the right to define misbehavior and offensive conduct and will act in accordance with the best interest of the Travel Abroad Program. Actions taken by the Group include and are not limited to sending the offending participant home at their own expense. Any student dependent on illegal drugs should not participate in this program. Students found to be using illegal drugs will be expelled and returned to Miami at their own expense. Breaches of local law will be reported to the requisite law enforcement agency of that country. Accommodations provided, whether hotel or student residence, are not for partying. No alcoholic beverages are permitted in hotel or other accommodations provided.

5. 6. 7. 8.

The reputation of the Paris-London-Dublin Travel Abroad Program, the Group, your country, and yourself is reflected in your personal behavior. You represent your College, your home country, and your accompanying professors and program leaders. You must conduct yourself accordingly with patience, respect for your hosts, and a sense of personal dignity. I, ______________________________________, have read the above statements, and I agree to abide by them to the best of my ability during my participation in the Paris-London-Dublin Travel Abroad Program. I understand the principles set forth above, and that violation of any of them may result in my expulsion from participation in the program, as indicated.

Signature: _____________________________________________ Date: ___________________________________