GRADUATE AND PROFESSIONAL INTERNATIONAL PROGRAMS FORM &
INTERNATIONAL TRAVEL WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY
AGREEMENT
FOR COUNTRIES WITH TRAVEL WARNINGS
- Please complete, sign & return to the Dean/Director with copy to International Programs
Student First Name
MI
Last Name
Program/Institution Name
Program Supervisor/Contact Name (if known)
Program Supervisor/Contact Email Address
Street Address
City
Departure Date
Name of Evacuation & Health Insurance Co.
Name of Trip Cancellation Insurance Co.
State
Country Zip
Date of Return
Policy #
Policy #
Duration of Coverage
Duration of Coverage
Student is requesting approval from Pacific University _______________(college) to travel to _____as
part of his or her academic experience. As a condition of Student’s participation in this international
educational experience, Student and Pacific University agree, as follows:
This is an approved clinical rotation/course and is considered part of Student’s educational experience
while attending Pacific University. Student understands that __________(country) is under a U.S.
State Department warning and the University reserves the right to withdraw its approval of this
rotation/course if travel risks escalate or if this country is included among the U.S. Treasury’s Office of
Foreign Assets Control (O.F.A.C.) list of Sanctioned Countries.
INDEMNIFICATION
Student expressly acknowledges and agrees that Pacific University is not responsible, nor
shall Pacific University be liable for any injury to or death of Student while traveling or
participating in the international educational experience referenced herein. Student
agrees to indemnify Pacific University and its Officers, Trustees, agents and employees and
hold them harmless from any and all claims, actions, suits, procedures, costs, expenses,
damages and liabilities, including attorney fees brought as a result of Student’s travel to
and within__________________(Country) including Student’s participation in the subject
international educational experience and, further, to reimburse the University for any such
expenses incurred.
REQUIRED PROOF OF INSURANCE
Student agrees to purchase and provide the office of the Dean of the College ____________ with the
following certificates of insurance coverage: Travel interruption and cancellation insurance policy;
Student has read the U.S. Secretary of State Travel Warnings in effect for the country of ______at
http://travel.state.gov/travel/cis_pa_tw/tw/tw_923.html?css=print and is aware of the risk of harm that is
assumed in traveling to this country under the current Travel Warning. Student is aware that inherent
in any travel to this country under the current Travel Warning Student shall be exposed to potential
violence, disease and the risk of bodily harm, even potential death.
Updated information on travel and security in this country may be obtained from the Department of
State by calling 1-888-407-4747
ASSUMPTION OF RISK AND WAIVER OF LIABILITY
Student, on behalf of Student and Student’s heirs and beneficiaries hereby assumes all risk
inherent in travel to and within _____________(Country) related to Student’s participation
in the international educational experience referenced herein. Student hereby expressly
releases Pacific University, its Officers, Trustees, agents and employees from any and all
liability, damages or causes of action, whether known or unknown, whether in tort,
contract, or based on statute, relating to Student’s participation in the above-referenced
international educational experience including, but not limited to, Student’s travel to and
within ______________(Country). This release specifically includes, but is not limited to, all
claims for relief or remedy, including all claims for attorneys’ fees, under any state, US
federal laws, or foreign laws.
Student further expressly agrees that this Waiver of Liability, Assumption of Risk and
Indemnity Agreement is intended to be as broad and inclusive as is permitted by the laws
of the State of Oregon and the United States of America, and that if any portion of this
Agreement is held invalid, it is agreed that the remaining provisions of the Agreement
shall continue in full legal force and effect.
I (also referred to herein as “Student”) have read all provisions of this Waiver of Liability,
Assumption of Risk, and Indemnity Agreement and I fully understand their meaning and
effect. I further understand that I am giving up substantial rights, including my right to sue.
I acknowledge that I am signing this Agreement freely and voluntarily, and intend by my
signature that this Agreement shall operate as a complete and unconditional release of all
liability with respect to Pacific University and its Officers, Trustees, agents and employees
to the greatest extent allowed by law.
Student Signature:____________________________________________________
Date:_____________
Pacific University
By: ____________________________________________________________
Dean
Program Coordinator/Clinical Coordinator:
Print Name and
Title_________________________________________________________________