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OFFICE OF GLOBAL PROGRAMS
PHONE:
812-877-8810
global@rose-hulman.edu
ASSUMPTION OF RISK AND RELEASE WAIVER
for Student International Travel
This Assumption of Risk and Release Waiver applies to Rose-Hulman Institute of Technology and all of its trustees, officers, directors, managers, servants,
agents, faculty, staff, students, volunteers, employees, advisors and/or representatives.
By signing the Assumption of Risk and Release, the individual named below wishes to participate in the program/activity described below and recognizes
that there are risks of damage or injury arising from this event or from other activities (including travel) that may be associated with participation in this
program/activity.
Participant Name_____________________________________________________ RH ID#________________ Grad/Undergrad
First
dd/mm/yyyy
first/middle/last
Middle
(circle one)
Last
Male/Female Birthdate__________________ RH email_________________________________ Major_________ CM#__________
(circle one)
mm/dd/yyyy
Mobile #_________________________Citizenship Country_______________________ Visa Status_______ (attach passport/visa copy)
Program/Activity__________________________________________Start Date__________________End Date__________________
Destination___________________________________________________________________________________________________
City
ST/PR
Country
Emergency Family Contact Name____________________________________________Relationship to you___________________
Phone number________________________________________Email___________________________________________________
By his/her signature below, the participating individual knowingly, willingly, and voluntarily agrees to assume and/or incurs all risks of loss, impairment, damage,
or injury to person or property (including possible loss of life), that may be sustained or suffered by participation in this program whether or not the result in whole
or in part of acts or omissions, negligence, or other unintentional fault of the overseas hosting institution/event site or Rose-Hulman Institute of Technology. The
undersigned further agrees to abide by any and all rules, regulations, and policies to comply with all directions given by any representative of the international
program/activity. The participant understands that special Foreign Medical/Travel Abroad insurance is required to be obtained by the participant and be in place
for the duration of the program/activity. Such coverage must provide emergency services such as but not limited to; medical evacuation, emergency reunion,
repatriation of benefits, political evacuation, and terrorism coverage.
In addition, the participant (including his/her heirs, assigns, and personal representatives) agrees to release, hold harmless, and indemnify Rose-Hulman Institute
of Technology from and against any claims, demands, actions, causes of action, lawsuits, expenses, or losses (including attorneys’ fees) on account of property
damage or personal injury (including loss of life) arising out of or attributable to the individual’s travel to or participating in the international program/activity. RoseHulman suggests participants consider purchasing trip cancellation insurance in the event any trip may be cancelled and/or postponed. Participant agrees that
any cost/expenses incurred due to and/or related to this trip are the responsibility of the participant and such costs will not be reimbursed by Rose-Hulman in the
event the above noted trip may be cancelled for safety concerns and/or the participant’s failure to return required travel documents in the timeline required and
etc…
************************************************************************************************************************************************
The undersigned acknowledges and represents that he/she has read the foregoing statement and understands it. The
undersigned acknowledges that he/she is over eighteen (18) years of age (parent or guardian otherwise) and of sound mind.
The undersigned has executed and delivered this statement on this __________day of _____________________, 20________.
Participant’s
Signature_________________________________________
Signature and printed name of parent or guardian (if participant is
under18 years of age):
Printed
name_____________________________________________
Signature_________________________________________________
Printed name_________________________________
Relationship_________________________________
Revised August 2015—v5