Student__________________soc. sec. Number___________
The following statement is designed to protect all participants in Duke University's Foreign Programs: the Students, faculty, Duke University and the agencies and individuals cooperating with Duke University. We ask that all students and their parents sign this form to indicate their agreement and permission.
1. we understand that participation in the program is entirely voluntary and that any program of travel involves some element of risk. We agree that in partial consideration of Duke University's sponsoring this activity and permitting the student to participate, we will not attempt to hold Duke University, its Trusties, officers, agents or employees liable in damages for any injury or loss to person or property the student might sustain while so participating; and we herby release Duke University, its Trusties, officers, agents or employees from any liability whatsoever for any personal injury or property damage arising from participation in the program.
2. We understand that the University reserves the right to make cancellations, changes or substitutions in case of emergency or changed conditions or in the interest of the group. Should the University cancel the program, full refunds will be made unless the cancellation is due to political, natural, tecnological or other catastrophes beyond its control in which case Duke University will be able to refund only uncommitted and recoverable funds.
In addition we understand that the program's fees are based on airfares, lodging rates and travel costs expected to be in force and are subject to increase.
We also understand that if the student leaves the program for any reason after the balance due deadline set by the Office of Foreign Academic Programs, there will be no refund of tuition; program fees will be refunded to the extent that prior commitments have not been made. A Duke student who receives financial aid should understand that by signing this agreement he or she is obligated to pay the tuition and committed program fees and that charges will be put on the student's Bursar account.
3. We understsand that the student is a participant in a Duke University Foreign Academic Program is a representative of Duke University and the United States and by signing this agreement pledges to deport himself or herself in a manner that reflects favorably on both. The University may dicipline a student or dismiss him or her from the program for behavior detrimental to the program. A dismissed student will receive no refund.
4. We understand that Duke University requires that all students be covered by appropriate sickness and accident insurance and that they be financially responsible for all medical expenses. In addition, we understand that payment for medical expenses customarily will have to be advanced and reimbursement sought later from the carrier. (Name of student)___________is insured under policy number____________by____________________________(insuring company), for sickness and accident insurance. Date of Expiration of the policy___________________________. In addition, the student hereby assumes responsibility for all medical expenses incurred by and on behalf of the student while participating in a Duke University Foreign Academic Program.
Participants are required to obtain an International Student Identification card available for Duke students in the Registrar's Office for $18 and a passport photo. Your International Student I.D. number must be furnished before departure to the address listed below.
Duke University advises that students planning to operate a motor vehicle obtain liability and collision insurance that will cover him/her in the applicable foreign country(ies). Duke University also recommends that students insure their property from loss or theft.
We understand that the student must make provision before departure for continuation of medical treatments such as precriptions or special diets. No representation can be made by Duke University with respect to accessibility to services and facilities abroad. Any person who cannot travel independently or who needs any form of assistance must make arrangements for and be accompanied by a companion who is capable of and totally responsible for providing such assistance.
6. In the event (I) (we) cannot be reached to give (my) (our) consent, (I) (we) the undersigned parent(s) of____________________herby authorize Duke University's representative to consent for (me) (us) to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment or hospital care deemed necessary or advisable by a licensed physician during the period the student is enrolled in the Duke Program. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of Duke University to give specific consent to the diagnosis, treatment or hospital care which in the best judgement of a licensed physician is deemed advisable.
Icertify that I am the parent or legal guardian of the student named above; that I have read the entire preceding statement and I join in all the articles of the statement without reservation, granting my consent to all actions provided for herin.
Signature of Parent/Guardian___________________Date_______________Address (number&street)
_________________________________________________________________________________
City___________________State_______________________Zip Code__________
Telephone__________________________________________ area code number
Signature of student___________________Date______________
The signature of both the Parent or Legal Guardian and the student are required.
Please sign this form and return it to Duke in Italy-Jazz Summer 1996 Program, Professor Paul Jeffrey, Department of Music, Director of Jazz Studies 064 Mary Duke Biddle, Box 90665, Durham, NC 27708-0665, Tel: 1 (919) 660-3314; FAX: 660-3301
THE APPLICATION IS NOT COMPLETE WITHOUT THIS PROPERLY SIGNED DOCUMENT.
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