MINDBODY PASSPORT
INTERNATIONAL SEMINARS, COURSES & RETREATS
EXPLORE AND DISCOVER THE WORLD . . . BE INSPIRED
REGISTRATION FORM/LIABILITY WAIVER AND INDEMNIFICATION FORM
Please fill out:
1) The registration form, liability waiver and indemnification form and send with
2) Application form for the 2014 Summer School Sigmund Freud University
3) Submit to: leslee.brown@sfu.ac.at
You will then be sent an e-mail invoice with a secure payment link.
Send a € 250 (non refundable) registration fee (applied towards tuition) to
secure a space in The International Summer School 2014: Dream Analysis
and Existential Psychotherapy
Once the registration fee has been paid your registration space is secured for The SFU
2014 International Summer School
50% or half of the remaining balance must be paid prior to April 21,2014
(an e mail invoice with a secure payment link will be sent)
Balance in full must be paid by June 21, 2014 (an e mail invoice will be sent
with a secure payment link)
STUDENTS MUST HAVE TUITION PAID IN FULL PRIOR TO
INTERNATIONAL SUMMER SCHOOL 2014 TO ATTEND
Non-EU citizens must provide proof of travel health insurance prior to the
SFU 2014 summer school
Each program will have individual travel dates that will be specifically outlined or participants
will be notified, depending on the location, within one month of the trip beginning. The safety
and security of participants is of paramount importance. In the event that international affairs
appear to reflect the need for changes to a program, in Mindbody Passport’s sole discretion
Participants will be contacted as soon as Mindbody Passport deems it appropriate. Irrespective
participants are responsible for their own safety and security.
Participants are to make any health or mental health needs known, in writing, concurrent with
registration and again at least four weeks prior to departure to Mindbody Passport as well at
time of departure so that the leader can best be aware and address individual needs and
connect students with resources in-country, if needed and possible. Neither Mindbody
Passport nor its employees or leaders are medically trained and have no responsibility to
participants to provide any type of financial or health care to any participant nor each
participant is solely responsible for his/her own health and financial care. Based on in-country
health requirements, participants may be required to receive shots (e.g., vaccinations) prior to
travel and participants are advised to speak with their own health care professionals well in
advance prior to departure to insure that they have received proper pre-trip vaccinations and
treatments. The cost of these and/or related treatments and/or immunizations are the financial
responsibility of the participants. Participants should check with their health insurance carrier,
as many plans may cover the cost of health-related travel shots and treatments.
Although leaders will make every effort to prepare the participants for a journey abroad, no
amount of preparation guarantees an individual’s health and safety, but taking proper
precautions (e.g., health-related travel shots) will help. Participants must remain vigilant,
keeping their own health and safety a top priority. Communicating openly with the leader is a
best practice. Mindbody Passport is not affiliated with any educational or government
institution.
Registration to secure your space will be deemed complete with the following submitted:
1) Completed and signed Registration Waiver of Liability and Indemnification form
2) Completed and signed Application form for the 2014 Summer School Sigmund Freud
University
3) € 250 (non refundable) registration fee (applied towards tuition)
50% or half of the remaining balance must be paid prior to April 21th 2014
(an e mail invoice with a secure payment link will be sent)
Balance in full must be paid by June 21, 2014 (an e mail invoice will be sent
with a secure payment link)
STUDENTS MUST HAVE TUITION PAID IN FULL PRIOR TO
INTERNATIONAL SUMMER SCHOOL 2014 TO ATTEND
30 days prior to travel Participants must submit:
Copy of passport
*Travel abroad health insurance policy
* Non-EU citizens must send proof of travel health insurance
(EU citizens or visas exempt)
Each non EU participant will be required to provide / secure:
A policy of comprehensive health and accident insurance, which provides comprehensive
health and accident insurance policy for injuries and illnesses sustained or experienced
overseas, and, more specifically, in the country traveling while on the Program, as well as
emergency evacuation and repatriation of remains insurance.
During the trip, accepted participants are responsible for conducting themselves according to
the expectations outlined by the leader for the specific trip. Participants that do not abide by
these expectations will be sent back to their home city at their own expense prior to the end of
the study abroad program.
REFUND POLICY:
Once fees are paid, absent Mindbody Passport’s approval in its sole discretion, no refunds will
be issued, subject to Mindbody Passport’s cancellation of trip policy as set forth below.
Cancellation of trip:
Mindbody passport reserves the right to cancel any trip for any reason it deems appropriate
including but not limited to, low enrollment numbers, political instability and/or health
concerns in the host country and if so will refund such amounts, in its sole and exclusive
discretion it deems appropriate that have not been committed to third parties for services or
accommodations, minus an administrative fee.
Participants Signature: _____________________________________Date:____________
Leader Signature: ________________________________ Date: ___________________
Participant Application
Please use the checklist provided below to ensure that all required components of this
application have been completed before submission. This must be submitted electronically
Necessary Components
Completed and signed Participant Application form,
Completed and signed participant registration, Waiver of Liability and Indemnification form
BASIC PERSONAL INFORMATION
___________________________________________________________________________
___________ Legal Name Date of Birth
Sex (M/F)
___________________________________________________________________________
___________ Current Mailing Address
___________________________________________________________________________
___________ Permanent Home Address
___________________________________________________________________________
___________ Phone Number
Primary Email Address
___________________________________________________________________________
___________ Country of Citizenship Passport Number Passport Expiration Date
___________ If not a US Citizen, please describe residency status above
PROGRAM SPECIFICATION (what program are you registering for?)
Please select the appropriate housing and Tuition options:
_____All Inclusive (2 week option) 4 star boutique hotel (Hotel
Rathaus Wein und Design): International Summer School tuition,
housing 4 star hotel (shared accommodations) all breakfasts, 14 days
U-Bahn (subway) passes, all excursions/field trips, 4 lunches, 4
dinners, all events and SFU parties/gatherings, transportation for all
excursions, wine and cheese rooftop party, opening reception: € 4355
Euros
_____ All Inclusive (1 week option) 4 star boutique hotel (Hotel
Rathaus Wein und Design): International Summer School tuition,
housing 4 star hotel (shared accommodations), all breakfasts, 14 days
U-Bahn (subway) passes, all excursions/field trips, 4 lunches, 4
dinners, all events and SFU parties/gatherings, transportation for all
excursions, wine and cheese rooftop party, opening reception:
€ 2377 (1 week option)
Please select week:
_____Week 1 Dream Analysis
_____Week 2 Existential
All Inclusive 2 star hotel (www.pension-wild.com):
International Summer School tuition, housing 2 star hotel (shared
accommodations), all breakfasts, 14 days U-Bahn (subway) passes, all
excursions/field trips, 4 lunches, 4 dinners, all events and SFU
parties/gatherings, transportation for all excursions, wine and cheese
rooftop party, opening reception:
_____€ 3389 Euros, (both Weeks)
_____€ 1795 (1 week option)
______SFU International Summer School 2 weeks Tuition Only
(No housing, No excursions) € 1800euros
______ SFU International Summer School 1 week option Tuition Only
(No housing, no excursions) € 900
Please select week:
_____Week 1 Dream Analysis
_____Week 2 Existential
______SFU International Summer School 2 weeks including
excursions/field trips (no housing) all excursions/field trips, 4
lunches, 4 dinners, all events and SFU parties/gatherings,
transportation for all excursions, wine and cheese rooftop party,
opening reception € 2809 Euros
______SFU International Summer School 1 week option including
excursions/field trips (no housing) all excursions/field trips, 4
lunches, 4 dinners, all events and SFU parties/gatherings,
transportation for all excursions, wine and cheese rooftop party,
opening reception
€ 1609 Euros
Please select week:
_____Week 1 Dream Analysis
_____Week 2 Existential
Below please describe your experience travelling abroad.
HEALTH HISTORY & EMERGENCY CONTACT INFORMATION
All major and/or minor physical health or mental health conditions. Remember that allergies
and disorders can reach higher severity while travelling. Below, please disclose information of
all health or mental health concerns that may aid in providing assistance while abroad.
ALLERGIES
Please list any and all allergies you suffer from and the medication you take, relative to
the same. You are urged to carry all medications you may require.
MEDICATIONS
Please list any medicines you are taking on a daily, regular or as needed basis and indicate
how often and why each medication is taken. You are urged to carry all medications you
may require.
ADDITIONAL HEALTH CONDITIONS
Do you have any additional health conditions other than those previously listed (such as
surgeries, hospitalizations, significant injuries, chronic conditions, physical illness,
psychological illness) that may require special consideration before or during your travel
abroad experience? If yes, please explain.
Please note: Participants must bring an adequate supply of medication in their original bottles
when traveling abroad. Participants should also check with the Center for Disease Control and
receive the suggested immunizations/medications required prior to departure.
If you have any dietary restrictions or limitations, please provide details regarding that as well
and be advised that it may not be possible for you to accommodate such dietary restrictions.
Mindbody Passport makes no representation or warranty that it will be possible to
accommodate such restrictions.
EMERGENCY INFORMATION
___________________________________________________________________________
___________ Emergency Contact (Primary) Relationship
Phone Number (Cell
Preferred)
(Email Address)
___________________________________________________________________________
___________ Emergency Contact (Secondary)
Relationship
Phone Number (Cell
Preferred) (Email Address)
Medication allergy:
Reaction:
Treatment if exposed:
Food or environmental allergy:
Reaction:
Treatment if exposed:
Name of Medication:
How often taken:
For what condition:
Mindbody passport will hold emergency contact information for participants on abroad
programs
Please notify program leaders of even slight health concerns while abroad to assist with
preparedness.
It is suggested that at least one of your emergency contacts maintains all contact information
with your primary care physician and/or such other medical personnel, as participant deems
appropriate
ADD EXTRA PAGES IF REQUIRED
WAIVER
The undersigned agrees to the following conditions:
In the case of an emergency, the Mindbody passport representative in charge may notify the
emergency contacts designated above and in that case may, but is not required, to also arrange
for any necessary medical care or treatment at my sole expense. It is further agreed that, if
required, the undersigned will willingly return to the United States at the sole expense of the
undersigned.
It is further agreed that in case of emergency, the undersigned, all successors, family, heirs,
third parties and personal representatives hereby waive and release Mindbody passport, its
affiliate organizations, officers, employees, attorneys, directors and agents from all liability
and expenses whatsoever sustained by the undersigned during and in coordination with the
abroad program.
It is further agreed, that in the event of an abroad location being deemed unfit to host a group
due to safety, health or any other serious concerns, and is so deemed without ample timing
before the departure date, the undersigned acknowledges that while Mindbody passport will
attempt to adjust travel arrangements, Mindbody passport is not responsible to replace,
reimburse, or compensate the undersigned in any way.
The undersigned certifies that all content on this abroad application is complete and accurate
and that should any of the information require updating, Mindbody passport will be promptly
notified.
Participants recognize that they may be photographed and/or identified in a visual and/or
auditory fashion during the Program and agrees that Mindbody Passport may use all such
visual and/or auditory for any purpose it deems appropriate and grants Mindbody Passport all
rights related thereto and relinquishes the same.
___________________________
Abroad Applicant Signature Date
INTERNATIONAL SEMINARS, COURSES & RETREATS Program
Participant Assumption of Risk, Waiver of Liability, and Indemnification Agreement
This Assumption of Risk, Waiver of Liability, and Indemnification Agreement (the
“Agreement”) is entered into by all participants of Mindbody Passport Abroad Programs. The
term “participants” as used herein includes participants, staff, and all other persons that
participate and travel in association with such Programs.
I have voluntarily agreed to participate in Mindbody passport INTERNATIONAL
SEMINARS, COURSES & RETREATS or Abroad Program traveling to Vienna
Austria [Country] from the date of July21,2014 [Starting Date)
through August 4, 2014 (the “Program”). I understand and hereby acknowledge that I am not
required to participate in the Program and that my participation in the Program is wholly
voluntary. In consideration of Mindbody passport consent of my participation in the Program,
the same having been received and acknowledged as sufficient, I hereby agree to the
following:
1. ACKNOWLEDGMENTS AND ASSUMPTION OF RISK
(a) I have read all documents and understood all documents provided by Mindbody
Passport and understand that participation in Mindbody passport INTERNATIONAL
SEMINARS, COURSES & RETREATS or Abroad Programs involves risks,
hazards, and dangers). I am aware of, understand, acknowledge, and appreciate that these
risks, dangers, and hazards involve traveling to and within, and returning from, one or more
foreign countries, including risks of air travel and all other types of transportation that could
result in damage to property, injury to persons, or death; foreign political, legal, social, and
economic conditions; different standards of design, safety and maintenance of utilities,
including computing facilities, buildings, public places and conveyances; and local sanitation,
medical, and weather conditions. I am aware of, understand, acknowledge, and appreciate the
risks, hazards, and dangers of travel to, in, and around the countries and territories being
visited, including but not limited to the dangers to my own health and personal safety,
including loss of property, personal injury, or death posed by war, terrorism, crime, civil
unrest, kidnapping, illness, public health risks, accidents, and/or violence. I am aware that
there are travel advisories issued by the U.S. Department of State and the Center for Disease
Control and other sources of information and material available to me and have had sufficient
opportunity to research the same and I have had the opportunity to make my own
investigation and I am willing to accept all such risks, hazards, and dangers.
(b) Knowing the risks, dangers, and hazards described above, and in consideration of being
permitted to participate in the Program, I agree, individually, and on behalf of my heirs,
family, successors, assigns and personal representatives, to assume all the risks, dangers,
hazards, and responsibilities surrounding my participation in the Program.
2. RELEASE
(a) In consideration of my participation in the Program, and to the maximum extent
permitted by law, I, individually, and on behalf of my heirs, family, successors, assigns and
personal representatives, hereby release and forever discharge Mindbody passport and its
employees, agents, officers, attorneys, directors, trustees and representatives (in all of their
official and/or individual capacities) from any and all liability whatsoever, arising out of or in
connection with my involvement in the Program, for any and all damages, losses or injuries
(including death) I sustain to my person or property or both, including but not limited to any
claims, demands, losses, actions, causes of action, suits or judgments, damages, expenses and
costs, including attorneys fees, which arise out of, result from, occur during or are connected
in any manner with my participation in the Program, any related or independent travel, any
activities or field trips, irrespective of whether they are sponsored, supervised or controlled by
Mindbody passport, and which arise as a result of negligence on the part of Mindbody
passport, its employees, agents, officers, trustees or representatives (in their official and
individual capacities).
3. INDEMNIFICATION
(a) I, individually, and on behalf of my heirs, successors, assigns and personal
representatives, hereby agree to indemnify, defend and hold harmless Mindbody passport and
its employees, agents, officers, trustees and representatives (in their official and individual
capacities) from any and all liability, loss, injury, damage, or expense, including attorney’s
fees, that may result from my negligent or intentional acts or omissions, which arise out of,
occur during, or are in any way connected with my participation in the Program, any related
or independent travel, any activities or field trips, irrespective of whether they are sponsored,
supervised or controlled by Mindbody passport
4.
STANDARDS OF CONDUCT
a) I understand that my behavior could impact the group as a whole and that the program
leader reserves the right to terminate my participation and that no refunds will be issued. It
will be my sole financial responsibility to make alternate travel arrangements should my
behavior result in termination from any mindbodypassport program.
(b) I understand and acknowledge that each foreign country has its own laws and standards
of acceptable conduct, including dress, manners, morals, politics, drug use, and behavior. I
recognize that behavior, which violates those laws or standards, could harm Mindbody
passport relations with those countries and the institutions therein, as well as my own health
and safety. I will become informed of, and will abide by, all such laws and standards for each
country to or through which I will travel during my participation in the Program, including
attending any and all Program orientation meetings and reading all materials the Program
provides. I will attend to any legal problems I encounter with any foreign nationals or
government of the host country or any country to or through which I travel during my
participation in the Program. Mindbody passport is not responsible for providing any
assistance under such circumstances.
(c) I understand and acknowledge that the leader from Mindbody passport will be the sole
judge of whether my actions hurt the Program, myself or others in the Program or seriously
offend the host culture. If they do, the leader or someone s/he appoints may unilaterally
terminate my participation in the Program. I understand and acknowledge that should my
participation in the Program be terminated, I will receive no refund of any fees, I am required
to leave the Program immediately, and that I am solely responsible for arranging and paying
for my own transportation back to the United States or my home country.
5.HEALTH AND SAFETY
(a) I hereby represent and warrant that I am responsible for carrying a policy of
comprehensive health and accident insurance, which provides comprehensive health and
accident insurance policy for injuries and illnesses I sustain or experience overseas, and, more
specifically, in the country that I will be traveling while on the Program, as well as emergency
evacuation and repatriation of remains insurance. MINDBODY PASSPORT MAINTAINS
NO TYPE OF SUCH COVERAGE FOR PARTICIPANTS.
(c) I agree to report, in writing, to Mindbody passport any physical or mental condition I
have, which may require special medical attention or accommodation during the Program as
early as possible, but no later than thirty (30) days prior to departure from the U.S. Mindbody
Passport will not be responsible for any accommodations and reserves the right to cancel any
participants registration it deems appropriate.
(d) I acknowledge and recognize that Mindbody passport is not obligated to attend to any of
my medical or medication needs, and I assume all risk and responsibility therefore. If I require
medical treatment or hospital care, in a foreign country or in the United States or my home
country, during my participation in the Program, Mindbody passport is not responsible for the
cost or quality of such treatment or care. Mindbody passport may (but is not obligated to) take
any actions it considers to be warranted under the circumstances regarding my health and
safety. I agree to pay all expenses related thereto and hereby release Mindbody passport its
employees, agents, officers, attorneys, directors, trustees or representatives (in their official
and individual capacities).
from any liability for any such actions.
6.
NON-PROGRAM AND PROGRAM ACTIVITIES
(a) I understand that if I spend any time away from the Program’s location, or participate in
any activity that is not a planned part of the program during the program (such as a field trip)
that I will give to the Program Director not less than two days prior to departure each time I
intend to leave for independent travel or activities. The Program leader and Mindbody
Passport has the discretion to deny time away requests but has no responsibility to do so and
has no responsibility to the Participants in this regard. Participants are not entitled to depart
the trip and return at a later date and time. I hereby represent and warrant that my participation
in these activities is not required by Mindbody passport and is wholly voluntary. I understand
and hereby acknowledge that I may face additional and/or increased risk of injury or death
due to physical conditions on site, civil unrest, violence, terrorism, crime, illnesses,
kidnapping, or political instability by traveling as part of the Program and/or away from the
Program’s location. I hereby assume, knowingly and voluntarily, each of these risks and all
other risks that could arise out of or occur during my travel to, from, in or around all Program
locations.
7. MISCELLANEOUS
(a) I understand and acknowledge that Mindbody passport does not represent or act as an
agent for, and cannot control the acts or omissions of, any host institution, host family,
transportation carrier, hotel, tour organizer, or other provider of goods or services relation to
the Program.
(b) I understand and acknowledge that Mindbody passport reserves the right to make
changes to the Program (including equipment substitutions or alterations in the proposed
itinerary) at any time and for any reason, with or without notice, and -shall not be liable for
any loss whatsoever to me by reason of any such cancellation or change. Mindbody passport
is not responsible for penalties assessed by air, land, water carriers and/or other transportation
that may result due to operation and/or itinerary changes, regardless of whether Mindbody
passport makes such arrangement. Mindbody passport, reserves the right to substitute hotels
or accommodations or housing of a similar category at any time. Specific room and housing
assignments are within the sole discretion of Mindbody passport.
(c) I understand and acknowledge that Mindbody passport 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 Mindbody passport, force majeure, war,
quarantine, civil unrest, kidnapping, public health risks, criminal activity, terrorism, expense,
accident, injuries, damage to and lost 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
Mindbody passport control, with or without notice; or for any additional expense occasioned
by any of the foregoing. If due to weather, flight schedules or other uncontrollable factors I
am required to spend additional nights Mindbody passport will not be responsible for my
hotel, transfers, meal costs or other expenses. My baggage and personal property are
transported at my risk entirely.
(d) The right is reserved by Mindbody passport, in its sole discretion, to cancel the Program
or any aspect thereof prior to departure; and, in Mindbody passport’s sole discretion to cancel
the Program or any aspect thereof after departure, requiring that all participants return to the
United States or my home country. If Mindbody passport determines or believes that any
person is or will be in danger if the Program or any aspect thereof is continued. If the Program
is changed or cancelled, the only responsibility of the Program is to refund to me all
uncommitted monies and deposits, if any, I have paid to the program. If changes in the
Program are minor, in Mindbody Passport’s sole discretion, the Program does not have to
refund any amounts to me.
(e) The Program may reproduce and use for educational or marketing purposes without
compensation all photographs, videos, movies, or sound recordings taken of me during the
time I participate in the Program.
(f) I agree that this Agreement is to be construed and governed under the laws of the State
of California, U.S.A.; and that if any portion hereof is held invalid, the balance hereof shall,
notwithstanding, continue in full legal force and effect.
MY SIGNATURE BELOW ACKNOWLEDGES THAT I HAVE READ THIS ENTIRE
DOCUMENT, THAT I UNDERSTAND ITS TERMS, AND THAT I AGREE TO
EVERYTHING STATED IN IT. FURTHER, NO REPRESENTATIONS, STATEMENTS,
OR INDUCEMENTS, ORAL OR WRITTEN, APART FROM THE FOREGOING
WRITTEN STATEMENT, HAVE BEEN MADE. MY SIGNATURE ALSO INDICATES
THAT I AM AWARE OF ANY SPECIAL RISKS, DANGERS, AND HAZARDS
INVOLVED IN THE PROGRAM, AND THAT BY SIGNING I AM GIVING UP
SUBSTANTIAL LEGAL RIGHTS I MIGHT OTHERWISE HAVE, AND THAT I HAVE
SIGNED IT KNOWINGLY AND VOLUNTARILY.
Name of Program ____
SIGMEND FREUD UNIVERSITY VIENNA INTERNATIONAL SUMMER SCHOOL
July 21-August 4, 2014:
DREAM ANALYSIS AND EXISTENTIAL PSYCHOTHERAPY
Participant’s Name (printed)________________________________________________
Date___________________________
Participant’s Name
(signature)_______________________________________________________________
Date____________________________