Field:
_______________________
Location:
_______________________
iJet Rating:
_______________________
Departure Date: _______________________
GRADUATE GLOBAL PRACTICUM
ORIENTATION CHECKLIST
Please complete and return this packet
AND A COPY OF YOUR PASSPORT via
e-mail to your Academic Advisor, including:
Please keep a copy of this packet for your
records, including:

 Consent
and Release Agreement
 Emergency Contact Information
 Trip Information
 Assumption of Risks (for countries rated by iJet as
level 4 or 5)
 A copy of your passport (.jpg or .pdf)




Communication and Contingency Plan
ACE Travel Assistance Program Information
Security Risk Assessment from
iJet/WorldCue (Provided in follow-up
e-mail from International Programs office)
Consular Information Sheet from State Dept
(Provided in follow-up e-mail from International
Programs office)
Traveler’s Health Information from CDC
(Provided in follow-up e-mail from International
Programs office)
______________________________________________________
Signature of Student
_______________________________
Date
______________________________________________________
Signature of Academic Advisor
Must e-mail completed packet and copy of passport to Academic Advisor.
_______________________________
Date
______________________________________________________
Signature of Faculty Supervisor
For countries rated by iJet as level 4 or 5, must e-mail completed packet to
Academic Advisor and Faculty Supervisor.
_______________________________
Date
______________________________________________________
Signature of Director of International Programs
_______________________________
Date
Last updated February 7, 2013
CONSENT AND RELEASE AGREEMENT
Name (print):________________________________
SIS Program: ___________________________________
The following agreement is designed to protect American University ("University"), as well as all participants, members,
agencies, and individuals cooperating with American University’s Graduate Global Practicum ("Program"). You, the student
(referred to as "I" in this agreement), must sign and return this form indicating agreement to the conditions herein set forth.
Confirmation of your participation will not be made without your signature.
As a participant in the Program, I am subject to the Code of Conduct as provided in American University’s current Student
Handbook. The information is available on the Internet at http://www.american.edu/handbook/. To receive a printed copy of
the Student Handbook, I may request one from American University's Office of the Dean of Students. I will also comply with
the University’s International Travel and Safety Policy. The information is available at
http://www.american.edu/finance/rmo/.
As stated in the University’s Code of Conduct, if a student violates the Code or if it is determined by the Program
Representative or agent or the Dean of the School of International Service that a student has violated this code, disciplinary
action will result.
Therefore, I understand that appropriate behavior, as outlined by the Student Handbook, is expected at all times. I further
understand that my participation in the Program may be revoked immediately, should I violate any of the codes established by
the Student Handbook.
1. General Release
I understand that participation in the Program is entirely voluntary and that any program of travel involves some element of
risk. I agree that in partial consideration of American University’s sponsoring this activity and permitting me to participate, I, my
parents, guardians or legal representatives will not hold American University, its trustees, officers, employees, or agents liable for
any injury, death, or loss to person or property sustained by me while participating in or arising out of any travel or activity
conducted by or under the auspices of American University’s Program.
2. Program Changes or Termination
I understand that the University reserves the right to make cancellations, changes, or substitutions in cases of emergencies or
changed conditions. I understand that any refunds made for programs where payment is made to the University will be in
accordance with published University policies for the academic year in which the Program occurs, unless otherwise stated.
3. Accident and Insurance Coverage
I understand that the University requires that all students be covered by appropriate accident and medical insurance including
the University’s International Emergency Health Insurance, and that all students be financially responsible for such expenses.
Further, I agree to provide the Program proof of medical insurance coverage. I also assure the University that there are no
health-related reasons or problems of which I am aware that preclude or restrict me from participating in the Program. I also
understand that the University’s International Emergency Health Insurance policy is valid only to the extent to which I adhere
to all policies and procedures of the study abroad program in which I am enrolled.
4. Motor Vehicle and Personal Property Insurance Coverage
I understand that the University requires students who plan to operate a motor vehicle to obtain liability and collision insurance
that will cover them in the applicable locale and that the University is not responsible for accidents or injuries which occur as a
result of a student’s operation of a motor vehicle while attending a Program. I also understand that the University recommends
that students insure their personal property from loss or theft and that the University is not responsible for loss or theft of
personal property.
5. Medical Treatment
I understand that while I am overseas, an emergency may develop which necessitates medical care, hospitalization, or surgery.
Wherever possible, a Program Representative or agent will contact my parents or guardians prior to such treatment. However,
this may not be practical depending upon the nature of the emergency. Therefore, I authorize the University through its
authorized Program Representative or agent to secure any necessary emergency medical treatment including the administration
2
of anesthesia and surgery. I understand that such treatment will be solely at my expense and I agree to reimburse the University
for any expense that it might incur on account of my injury or treatment.
6. Housing Arrangements
I understand I am responsible for my own housing arrangements and I will be responsible for the full cost of the
accommodations. Housing sites may have rules above and beyond those mentioned herein and I will need to abide by those as
stipulated by the specific program.
7. Voluntary or Involuntary Withdrawal or Dismissal
I understand that I am subject to University regulations, Program guidelines, and laws of the host country. In the event of
violation of any of the above, academic failure, or behavior which is detrimental to me, the Dean will have the right to dismiss
me from the Program. The decision is final and may result in the loss of academic credit for the Program. I recognize that due
to the circumstances of foreign study programs, procedures for notice, hearing and appeal applicable to student disciplinary
proceedings at the University do not apply. If I am dismissed, I consent to being sent home at my own expense with no refund
of fees. I further understand that I may also be subject to Conduct Council charges for violations of University policies or code
of conduct.
8. Legal Conflicts
I acknowledge and understand that should I be arrested or come into legal conflicts in the host country, I must attend to this
matter personally and use my own funds to cover any costs of such problems. I understand that the University is not
responsible for providing legal assistance in these circumstances. I understand and agree that I am liable for damages to my own
person and property, as well as damages to other persons and their property, including any damage due to my abuse of alcoholic
beverages, medicines, and/or illegal drugs. I recognize that I am personally liable for the legal and economic consequences of
my actions and I have been so notified.
9. Governing Forum
I further understand that this Agreement will be construed in accordance with the laws of the District of Columbia, which will
be the forum of any lawsuits filed under or related to this Agreement or Program. The term and provisions of this Agreement
will be severable, such that if a court of competent jurisdiction holds any term to be illegal, unenforceable, or in conflict with
any law governing this Agreement the validity of the remaining portions will not be affected thereby.
10. Pledge
I agree to comply fully with the rules of the University and its agents, its host institutions and/or any cooperating entity. I agree
that the University has the right to enforce its standards of conduct and that should I fail to comply with them, the University
has the right to terminate my participation in the Program with no refund of monies paid.
I HAVE READ AND UNDERSTAND THE ABOVE PROVISIONS AND AGREE TO BE BOUND BY THEM.
Student Signature: _______________________________
Date: ____________________________________________
Social Security #: ________________________________
AU ID #: ________________________________________
Citizenship: ____________________________________
Passport #: _______________________________________
Date of Birth: ___________________________________
Student Address (home) : ______________________________________________________________________________
USA Telephone Number: ____________________________ E-mail address: ____________________________________
3
EMERGENCY CONTACT INFORMATION
Student Name: __________________________________ SIS Program: _______________________________
AU ID #: ___________________
DOB: ___________________ Gender:
□ Male
□ Female
E-mail address: __________________________ In-country phone number: ____________________________
Please list two people you would like SIS to contact in the event of an emergency. At least one contact
must be a parent/guardian, regardless of language background.
Contact Person:
________________________________________
Relationship to student: _______________________________________________________
Telephone Number: ____________________________ E-mail: ________________________________
Address: _____________________________________________________________________________
Other: _______________________________________________________________________________
Contact Person:
________________________________________
Relationship to student: _______________________________________________________
Telephone Number: ____________________________ E-mail: ________________________________
Address: _____________________________________________________________________________
Other: _______________________________________________________________________________
PERSONAL HEALTH INSURANCE INFORMATION
Do you have any medical conditions or physical limitations that SIS should be aware of?
□ No □ Yes If yes, please provide in a sealed envelope a statement which explains your condition. All disclosures will be
kept confidential.
Is your insurance provided through AU?
If not, provide information here:
□ Yes
□ No
Provider name: _______________________
Policy number: _______________________
Expiration date: ______________________
4
TRIP INFORMATION
Student Name: __________________________________ SIS Program: ________________________________
AU ID #: ___________________
DOB: ___________________ Gender:
□ Male
□ Female
E-mail address: __________________________ In-country phone number: ____________________________
Registration Information:
Term:
Fall
Spring
Summer
Year: __________
Course #: _______________ Title: ___________________________________ # Credits: __________
Faculty Supervisor: _________________________________________________
Travel Dates:
Departure Date: _________________________ Return Date: ______________________________
iJet Rating(s):
Destination Information:
Cities and Countries Visiting: ______________________________________________________________
(for academic work)
Organization Information (if applicable):
Internship and/or Research Organization: ____________________________________________
Site Supervisor Name and E-mail Address: ____________________________________________
Student’s International Address (required):
Address: ___________________________________________________________________________
___________________________________________________________________________
Phone: ____________________________
Fax: ________________________________
E-mail: _______________________________________
International Emergency Contact Information (required):
Name: _________________________________________________
Organization: ____________________________________________
Address: ___________________________________________________________________________
___________________________________________________________________________
Phone: ____________________________
Fax: ______________________________
E-mail: _______________________________________
5
ASSUMPTION OF RISK AND WAIVER OF LIABILITY
AMERICAN UNIVERSITY
(For students traveling to a country rated by iJet as a 4 or 5)
THIS IS A RELEASE OF LEGAL RIGHTS - READ AND UNDERSTAND BEFORE SIGNING.
Student Name: __________________________________ (“Participant” or “I”)
AU ID #: ___________________
DOB: ___________________ Gender:
□ Male
□ Female
E-mail address: __________________________ In-country phone number: ____________________________
Project Description: ________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
As a condition of participation, I hereby acknowledge and agree as follows:
1. Assumption of Risks.
I acknowledge that the decision to participate in this Project is entirely my own choice, voluntary, and not a
condition of my employment or status at the University. I understand that participation in the Project involves risks
not normally found in employment at the University. I understand that I will travel to
_________________________, a country that has recently experienced terrorist attacks and civil unrest.
I am aware that no special security personnel will be provided, and American University cannot guarantee my
security. I am aware that the political circumstances during the time I will be in __________________ may
adversely affect transportation, medical care, and housing and the quality of food and water. The Project risks are
substantial and include without limitation risk of death or serious bodily injury. I agree that it is my sole
responsibility to investigate and evaluate for myself serious bodily injury. I agree that it is my sole responsibility to
investigate and evaluate for myself the risks associated with this Project. By my participation, I am willing to accept
these risks.
2. Health and Safety.
a. I have consulted with a medical doctor regarding my personal medical needs. I certify that I am fit to
participate in the Project and that there are no health-related reasons or problems, which preclude or restrict
my participation in this Project.
b. I am aware of all applicable personal medical needs. I have arranged, through insurance or otherwise, to
meet any and all needs for payment of medical costs while I participate in the Project.
c. I agree to maintain a high level of vigilance and to take appropriate steps to increase my security awareness,
including consulting with U.S. Department of State guidelines for security in _______________________.
I agree to conduct myself in a safe and prudent manner at all times.
3. Waiver of Liability.
Knowing the risks described above, I, on behalf of myself, my family, heirs, representatives, accept those risks and
hereby release, discharge and agree to hold harmless American University, its trustees, officers, employees, agents,
from any and all liability, claims, demands, rights, causes of action for personal illness, injuries or death, or any
damage to or loss of personal property which may occur en route to, during, from or as a result of my participation
in the Project.
I have carefully read this Assumption of Risk and Waiver of Liability before signing it. No representations,
statements, or inducements, oral or written, apart from the foregoing written statement, have been made.
______________________________________________________
Signature
6
_______________________________
Date
COMMUNICATION AND CONTINGENCY PLAN
TAKE THIS FORM WITH YOU
If you have concerns about academic issues, please contact your advisor in SIS Graduate Academic
Affairs. You may contact him/her personally, by calling (202) 885-1690 or by sending an email to
sisgradadvising@american.edu.
In the event of an emergency while you are abroad, your contacts at American University are as follows:
Jeannie Khouri
Director of International Programs, SIS
Office: 202.885.1685, Mobile: 703.201.1703
E-mail: khouri@american.edu
Leeanne Dunsmore
Associate Dean, SIS
Work: 202.885.1617, Home: 301.929.3383
Email: leeanne@american.edu
Main SIS Office
202.885.1600
AU Campus Security
Emergency: 202.885.3636
7
TAKE THIS FORM WITH YOU
ACE Travel Assistance Program
For students, faculty and staff traveling or stationed abroad not in their country of
permanent residence.
INSURANCE PROVIDER AND
INFORMATION
TRAVEL ASSISTANCE PROGRAM
ACE USA provides primary coverage.
Europ Assistance is a service provider.
Medical Assistance including referral to
a doctor or medical specialist, medical
monitoring when you are hospitalized,
emergency medical evacuation to an
adequate facility, medically necessary
repatriation and return of mortal
remains. (See reverse side for details.)
• Personal Assistance including pre-trip
medical referral information, and while
you are on a trip: emergency medication,
embassy and consular information, lost
document assistance, emergency
message transmission, emergency cash
advance, emergency referral to a lawyer,
translator or interpreter access, medical
benefits verification and medical claims
assistance.
• Travel Assistance including emergency
travel arrangements, arrangements for
the return of your travelling companion
or dependents and vehicle return.
• Political/Natural Disaster Evacuation
including transportation and related costs
to the nearest place of safety within 14
days of qualifying event (up to $25,000).
Plan Number: 01AH585
Policy Number: GLM N00173587
Insured: American University
Assistance Provider: Europ Assistance
USA
Call Europ Assistance when:





You require referral to a hospital or doctor
You are hospitalized
You need to be evacuated or repatriated
You need to guarantee payment for
medical expenses
You experience local communication
problems
Europ Assistance can be reached at
1-800-243-6124 inside the USA. Call
collect at 1-202-659-7803 if you are
outside the USA. Before you call, please
have ready the following information:
1.
2.
3.
4.
5.
6.
By requesting assistance you agree to assign to us
your rights to recover from any of your
responsible insurers any expenses we incurred.
Name of caller, phone number, fax
number, relationship to patient
Patient’s name, age, sex, policy number
A description of the patient’s condition
Name, location, telephone number of
hospital
Name and telephone number for the
treating doctor (where and when s/he can
be reached)
Health insurance information, worker’s
compensation, or automobile insurance
information if the patient had an accident.
This information provides you with a brief outline
of the services available to you. These services
are subject to the terms and conditions of the
policy under which you are insured. A third party
vendor may provide services to you. Europ
Assistance makes every effort to refer you to
appropriate medical and other service providers.
It is not responsible for the quality or results of
service provided by independent providers.
If you need to file a claim with ACE USA after
having received medical services abroad for
which payment was not made directly by
ACE USA, please contact Europ Assistance to
obtain claim information.
In all cases, the medical provider, facility, legal
counsel or other professional service provider
suggested by Europ Assistance are not employees
or agents of Europ Assistance and the choice of
provider is yours alone. Europ Assistance
assumes no liability for services provided to you
under this arrangement, nor is it liable for any of
the legal or health care professionals providing
services to you. Travel assistance services are
not available if your coverage under the policy
providing Business Travel Accident Insurance
benefits is not in effect.
8
GLOBAL ACCIDENT & HEALTH BENEFITS
Benefits
Medical
expenses
Description and Limits











Up to $50,000
Deductible

$50.00 (per occurance)
Pre-existing
Conditions


Up to $2,500
Exclusions
included, but
not limited to











Routine physical examinations
Medical
evacuation


Up to $50,000
Medical
repatriation


Up to $50,000
Accidental
death and
dismemberment
Executive
Assistance
services

Up to $10,000






24hours a day/365 days a year



Legal-referral to lawyer
Medical care and treatment provided by a physician as a result of a sickness or accident
Semi-private hospital room and board
All necessary medical and surgical services and supplies while confined in a hospital
Outpatient medical care and treatment provided by a hospital or clinic
Professional local ambulance service
Dental expenses resulting from an accident up to $1,000
A surgical procedure and anesthesia when performed or administered by a physician
Laboratory and x-ray tests and treatments
Supplies and prescriptions while confined in a hospital or upon release
$2,000 per pregnancy benefit for emergency medical services
Defined as any condition that a covered person has incurred charges, received medical treatment or taken prescribed drugs or
medicine for an injury or sickness during the 90 day period immediately preceding the date of travel.
Eyeglasses
Hearing aids
Routine dental care
Cosmetic treatment or surgery
Confinement or institutional care
Maternity and routine nursery care
Expenses incurred during holiday travel
Injury or sickness caused by war, riot, civil commotion or police action
Participation in a criminal act
Intentionally self-inflicted injuries
Emergency evacuation to an adequate medical facility
Medically necessary repatriation and return of mortal remains
Inside the USA or Canada 1-800-766-8206
Outside USA or Canada collect 1-202-659-7777
Medical-referral to medical specialist or medical monitoring while hospitalized
Travel-emergency travel arrangements, return of traveling companion/dependant and return of vehicle
Personal-pre-trip medical referral, emergency medication, embassy and consular information, lost document service, emergency
message transmission, emergency cash advance, translator/interpreter access
Security-Pinkerton Travel Security Services includes Eye on Travel security
Information and security briefings by phone.
9