Xavier MBA: International Study Trip Waivers
Contained within this PDF package are the required waiver forms that must be completed and returned
in order to be eligible for an international business study trip.
These forms include:
MBA Code of Conduct
Assumption of Risk and Release (AOR105) **This form may be trip specific. If so, a dedicated link will be on the website
Student Agreement (PA303)
to download the specific form. Do not fill out the regular form in this packet if
there is a specific one for your trip location.
Medical Waivers (MED202), includes:
Emergency Medical Care Form
Health History Health Screening Examination
Internet Release Form
In addition to the above forms, copies*of the following are also needed:
Valid Driver’s License
Signed Passport
Please complete each form and return them to Joliene Garlich in the Xavier MBA office.
If you have any questions, contact Joliene at 513‐745‐3476 or garlichj@xavier.edu.
*Copies can be made in the MBA office at the first pre-session meeting for the class associated with the trip. Completed documents
can also be turned in at this time.
XAVIER UNIVERSITY MBA Professional Code of Conduct Student name:__________________________________________________________________ Doing Business in:______________________________________________________ Dates of experience:_____________________________________________________________ Students who participate in the Xavier University MBA Study Abroad Program are representatives of Xavier for the duration of their time on the program. Students are expected to conduct themselves appropriately and respectfully and abide by the rules set forth by the Professor and MBA Office. Any student who engages in neglectful, disrespectful, hostile, or violent behavior that threatens him or herself, another student/professor/tour guide, or the program will be subject to immediate removal from the program and sent home at his or her own expense without refund. Academic disciplinary action will follow upon return home and after situation review by the Associate Dean of the Williams College of business. 1. Whereas I must be punctual for all, as well as attend, planned events and activities. 2. Whereas I must conduct myself in a professional manner in accordance with the corporate and academic environments. 3. Whereas I must conduct myself in a professional manner in regards to all aspects of socialization and alcohol consumption. An overconsumption of alcohol will result in a reduction of grade. 4. Whereas I must be accompanied by another Xavier student and/or the Lead Professor and/or the Lead Administrator for the duration of the above listed experience. 5. Whereas I promise to comply with the above listed MBA Code of Conduct policies. 6. Whereas I fully understand that failure to comply with said MBA Code of Conduct polices will result in a penalty ranging from an automatic reduction of 20% in my grade for this course to an F for this course. ____________________________________________________ Participant’s Signature Date Printed Name: ________________________________________ Date of Birth: _________________________________________ Xavier Banner ID: ___________________________________ Witnessed by: XU MBA Office: Student Agreement for XU MBA Student Off‐Campus Study Abroad Program 4/22/2010 AOR for XU Student – Off Campus Overnight Intl Fac/Empee Led
Form AOR105
Rev. 7/28/2008
XU Risk Management & Insurance
XAVIER UNIVERSITY
Assumption of Risk and Release for
___________________________________________ [name of experience]
____________________________________ [location and dates of experience]
I,
[student name] wish to participate in
____________________________________________________________ [name of program/event or
brief description of experience] on _____________________________ [dates] (the “Experience”)
as a student of Xavier University. I understand that this Experience will be conducted offcampus at _____________________________________________________ [off-campus location of
experience] (the “Location”) and unstable or unexpected conditions may require changes in
the planned Experience or might cause inconvenience or harm to me. I understand that
Xavier does not own, operate or control the Location. I also understand and agree that
Xavier University does not assume responsibility or liability for and has not made, does not
make, and cannot make any representations whatsoever regarding my personal health and
safety or that of my property while participating in this Experience.
I recognize that certain aspects of the cultural and political climate of the Location
may be materially different from that of my own culture or that of the Xavier Community.
I further recognize that any experiences or other activities in the Location may be very
different than exist in the Xavier Community or the United States. I realize that there may
be inherent risks to my health or wellbeing as a result of my participation in this
Experience, which Xavier University can neither anticipate nor ameliorate. Such risks
include but are not limited to any risk inherent in this type of Experience, inexperience or
unfamiliarity with this type of Experience or its requirements, unfamiliarity with the
Location, travel to, from and around the Location, unfamiliarity with the Location’s laws,
culture or customs, unfamiliarity with work environment conditions or requirements,
political instability, war, insurrection, rebellion, riot, violence, terrorism, exposure to
sickness or disease, allergic reaction, contaminated food or water, unfamiliar climate,
complications from weather conditions, inadequate or unavailable healthcare facilities or
assistance, inadequate, faulty, inappropriate or lack of training or instruction, inadequate,
faulty, inappropriate or lack of equipment, accident, or mistake. I recognize that these
risks may result in inconvenience, loss, injury, or damage to me, including personal injury,
up to and including my death, or damage or loss of my personal property.
I certify that I am physically and emotionally capable of full participation in this
Experience, however, I recognize that occasionally an individual participating in this type
of event may face a health emergency requiring local hospitalization or emergency
treatment. I have separately executed an Emergency Medical Care Authorization Form,
however, I understand Xavier is under no duty to secure such care or assist me in any other
way in the event of such a health emergency.
I promise to abide by all rules and requirements of my participation in this
Experience, including those set forth in the Student Agreement which I have separately
executed. I promise to exercise common sense and good judgment, and to conduct myself at
all times in a manner that is appropriate to this type of experience. I recognize that by
breaking any of these promises, or for any other reason deemed appropriate by Xavier
University or its representatives, my participation in this Experience may be immediately
terminated.
In consideration of Xavier University’s financial or other support of this
Experience, and because I am voluntarily participating in this Experience, I
This is the only form approved by Xavier University for this purpose.
It may not be modified or changed in any way.
1
AOR for XU Student – Off Campus Overnight Intl Fac/Empee Led
Form AOR105
Rev. 7/28/2008
XU Risk Management & Insurance
acknowledge and agree that I assume all risks associated with participating in
this Experience and agree to the terms set out in this Assumption of Risk and
Release (the “Agreement”). Further, I release Xavier University from all claims,
including negligence, that may arise from my participation in this Experience,
whether foreseen or unforeseen, known or unknown, and I assume full
responsibility for any injuries, damages, or losses that may arise out of my
participation in this Experience, up to and including my death.
I acknowledge that this Agreement shall bind me as well as my family members,
heirs, executors, administrators, personal representatives, dependents, successors and
assigns.
In this Agreement, “Xavier University” means Xavier University, all past and
present directors, trustees, officers, employees, agents, insurers, attorneys, and any other
party associated with Xavier University, including but not limited to any Xavier University
faculty members or employees that were involved in the planning of, making arrangements
for or conducting of this Experience. This Agreement shall be construed in accordance with
the laws of the State of Ohio. Should any portion of this Agreement be held invalid, the
remaining portion shall not be affected and shall continue to be valid and enforceable.
I certify that I have read and understand this Agreement, and I freely sign it,
acknowledging the significance and consequences doing so. I also acknowledge that I have
had all my questions answered to my satisfaction regarding this Experience and this
Assumption of Risk and Release.
By signing this Agreement, I assert that I am at least 18 years of age. If I am not
yet 18 years of age, I understand that my parent or legal guardian must also sign below
before I may participate in this Experience.
Participant’s Signature
Date
Printed Name:
Date of Birth:
Xavier Banner ID:
Parent/Guardian’s Signature
if under 18
Date
This form must be notarized:
STATE OF ___________________
COUNTY OF _________________
:
: SS
:
The foregoing instrument was sworn to before me and subscribed in my presence this _____
day of ____________, 20___.
________________________________
Notary Public
This is the only form approved by Xavier University for this purpose.
It may not be modified or changed in any way.
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Student Agreement for XU Student – Off Campus Overnight Intl Fac/Empee Led
Form PA303 MBA
Rev. 12/3/2008
XU Risk Management & Insurance
XAVIER UNIVERSITY
Student Agreement for
______________________________________________ [name of experience]
____________________________________ [location and dates of experience]
1. Whereas the purpose of this _______________________________________________________
[insert name of program/event or brief description of experience]
at _______________________________________[insert off-campus location of experience]
on _______________________________________[insert dates of trip] (the “Experience”)
fully participate in the course for MBA program credit
is to ___________________________________________[describe
the purpose of experience],
2. Whereas traveling and participating in the Experience can be physically and emotionally
challenging, exhausting, stressful and confusing,
3. Whereas I must be responsible not only for my own physical, intellectual, moral, and spiritual
needs, but also for those same needs of the other Xavier students,
4. Whereas I must look out not only for my own safety but also for that of the other Xavier
students,
5. Whereas alcohol consumption may impede the purpose of this Experience, whereas public
intoxication is especially dangerous when in an unfamiliar area, and whereas alcohol
consumption may be illegal for persons under a certain age,
6. Whereas selling, buying, possessing or using recreational drugs is illegal,
7. Whereas certain clothing (e.g., provocative, flashy, or impractical clothing) may be
unprofessional, draw unwanted attention, or be otherwise inappropriate,
8. Whereas the Student Handbook and all other University procedures continue to apply, and all
laws of the country or region that I am in (whether the United States or another country) apply
while I am participating in an off-campus activity,
9. Whereas by participating in this Experience I am representing Xavier University in general,
and whereas by participating in this Experience I am establishing a reputation for Xavier
students and for Xavier professors or employees who may participate in this Experience in the
future,
10. I promise to embrace this Experience with all my physical, mental, and spiritual abilities.
11. I certify that I am physically and emotionally capable of full participation in this Experience.
12. I promise to look out for my physical, intellectual, moral, and spiritual well-being, and for the
physical, intellectual, moral, and spiritual well-being of the other Xavier students.
13. I promise not to illegally consume, purchase or possess any alcohol at any time during the
Experience. Additionally, I agree to abide by the rules of this Experience regarding the
consumption, purchase or possession of alcohol, if any.
This is the only form approved by Xavier University for this purpose.
It may not be modified or changed in any way.
1
Student Agreement for XU Student – Off Campus Overnight Intl Fac/Empee Led
Form PA303 MBA
Rev. 12/3/2008
XU Risk Management & Insurance
14. I promise not to consume, purchase or possess any recreational drugs at any time during the
Experience.
15. I promise to wear conservative clothing and appropriate business attire at all times during the
Experience.
16. I promise not to engage at any time during this trip in any sort of romantic or sexual
relationship with anyone, including people I meet on the trip (including others from the United
States), and other Xavier students. I understand that in all lodging situations, rooms will be
expected to be single-sex specific. If I am visited during the program by a friend or significant
other, I promise to abide by the promises contained within this paragraph, as well as the rest of
this document, with respect to that visit.
17. I promise to be a good citizen and neighbor, to exercise common sense and good judgment, and
to conduct myself at all times in a manner that is sensitive to the feelings of the people with
whom I interact.
18. I promise to communicate with the Xavier faculty member or employee participating in this
Experience in a timely and straightforward manner about any difficulties I am experiencing
regarding the Experience and my fellow Xavier students. I understand that I may discontinue
my participation at any time.
19. I promise to abide by the participating Xavier faculty member or employee’s discretion
regarding any particular interpretation of any of these terms and promises, and I promise to
follow the participating Xavier faculty member or employee’s directions at all times.
20. I promise to let someone in the group know where I am at all times during this Experience.
21. I promise to abide by all rules and requirements of my participation in this Experience.
22. I recognize that by breaking any of these promises my participation in the Experience may be
immediately terminated, I may be sent directly back to Xavier University. I understand that if
I am separated from the Experience for any reason, I will continue to be responsible for all
Experience costs and any additional costs resulting from my early departure or dismissal.
Participant’s Signature
Date
Printed Name:
Date of Birth:
Xavier Banner ID: _________________________
Parent/Guardian’s Signature
if under 18
Date
This is the only form approved by Xavier University for this purpose.
It may not be modified or changed in any way.
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Medical Form for XU Student – Off Campus Overnight International
Form MED202
Rev. 7/28/2008
XU Risk Management & Insurance
XAVIER UNIVERSITY
Off-Campus Experience
Emergency Medical Care Authorization and Health History
Occasionally a Xavier student participating in a Xavier University Off-Campus Experience may
face a health emergency requiring local hospitalization or emergency treatment. I authorize Xavier
University, through its representatives, to secure emergency medical care, hospitalization or surgical
treatment or dental treatment for me during my participation in this Xavier University Off-Campus
Experience.
In the event of a medical emergency, Xavier University, through its representatives, will make
every effort to reach the person or persons designated below:
FIRST EMERGENCY CONTACT
SECOND EMERGENCY CONTACT
Name:
Name:
Relationship
Relationship:
Address
Address:
Telephone (day):
Telephone (day):
Telephone (evening):
Telephone (evening):
Cell Phone
Cell Phone:
E-Mail:
E-Mail:
Certificate of Medical Insurance Coverage
Xavier University requires that all students have insurance with medical coverage while
participating in an Off-Campus Experience. By signing below, I certify that I understand Xavier
University is not required to pay for any of my medical costs while I am participating in this Experience. I
further understand that Xavier University is not required to pay for any evacuation, reunion or
repatriation of remains costs that arise out of my participation in this Experience.
I certify that I will be covered by medical insurance with this type of coverage valid during the time
that I participate in this Off-Campus Experience, or that I understand and fully accept any and all
consequences of not being covered by such insurance during my participation in this Experience.
XU Student’s Signature:
Date:
Parent’s or Guardian’s Signature (if student is under age 18):_____________________
Printed Name of XU Student:
Date:
XU Banner ID:
Insurance Company (if applicable):_____________________ Policy Number (if applicable):
PLEASE ATTACH A COPY OF YOUR INSURANCE CARD, FRONT AND BACK
__________________________
A copy of this form will be kept at Campus Police and with the sponsoring department. The original
will be kept by the Experience organizer participating in the Off-Campus Experience.
This is the only form approved by Xavier University for this purpose.
It may not be modified or changed in any way.
1
Medical Form for XU Student – Off Campus Overnight International
Form MED202
Rev. 7/28/2008
XU Risk Management & Insurance
HEALTH HISTORY
The following information concerning medical history, including allergies, medications
being taken, and physical impairments, to which a physician should be alerted:
GENERAL INFORMATION
( ) Male
(LAST NAME)
(FIRST)
(MIDDLE)
( ) Female
(BIRTH DATE)
PERMANENT MAILING ADDRESS:
(STREET)
(CITY)
(STATE)
(ZIP CODE)
(TELEPHONE)
HEALTH PROBLEMS – List any continuing health problems:
DRUG ALLERGIES AND REACTION – List any drug allergies and briefly describe what happened:
MEDICINES – List any medicines, pills or injections (prescription and over-the-counter) you take
regularly:
HISTORY – Check if you have ever had any of the following:
Anemia
Asthma/hay fever/allergy
Back problems
Bladder/kidney problem
Heart problems (describe)
Jaundice/hepatitis
Protein/sugar in urine
Surgery
(TYPE AND YEAR)
Epilepsy/convulsions
High blood pressure
Ulcer/stomach problem
No
Emotional/Mental problems
Drug/Alcohol problems
Have you ever lived in close contact with anyone who had tuberculosis?
TB skin test:
negative
year
TB Medicines Taken:
positive
year
never tested
Anything else that we should be aware of?
FAMILY MEDICAL HISTORY
Has anyone in your family had any of the following problems?
Asthma/hay fever
Diabetes
Heart disease
High blood pressure
Sickle cell/anemias
__________________________
A copy of this form will be kept at Campus Police and with the sponsoring department. The original
will be kept by the Experience organizer participating in the Off-Campus Experience.
This is the only form approved by Xavier University for this purpose.
It may not be modified or changed in any way.
2
Medical Form for XU Student – Off Campus Overnight International
Form MED202
Rev. 7/28/2008
XU Risk Management & Insurance
Xavier University
Health Screening Examination
(To be performed by a physician or other health care provider)
A physician or other health care provider should complete this form after
reviewing the student’s Health History Form with the student. For students seeing a
specialist for a serious ongoing condition, the approval of the specialist must also be
obtained.
I have completed a history and physical examination of Xavier Student, ________________,
and determined that he or she is in good physical and mental health. I do not foresee any
medical problems that would interfere with his or her full participation in the Off-Campus
Experience in _____________________________________________.
Physician’s Signature: ____________________________________________________________________
Physician’s Name: _______________________________________________ Date: ___________________
__________________________
A copy of this form will be kept at Campus Police and with the sponsoring department. The original
will be kept by the Experience organizer participating in the Off-Campus Experience.
This is the only form approved by Xavier University for this purpose.
It may not be modified or changed in any way.
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CONSENT TO PUBLISH STUDENT WORKS ON THE INTERNET
RELEASE FORM
2/11/2009
This document gives WCB/MBA office permission to publish works created by students in the course of [int'l immersion], and/or
to use sound,photographs and/or video of the students, on the Internet and/or in other multimedia environments.
_____________________________________________________________________________________________
(Name of student) _____________________________________________________________________________________________
(Address) Under the conditions and terms set forth below, I give permission to [the department or faculty member] to use my works, audio, photographs or video of me, and/or my name for the class web site [http://www...] and/or on other web sites and media, for nonprofit educational uses, as well as for the purposes of professional development and promotion of [the department or faculty member]’s activities. 1. I retain ownership of the intellectual property and copyright for my works. If appropriate and necessary, I will submit text for a credit line to assure that I receive proper attribution for my work. 2. By giving this permission, [the department or faculty member] can use and edit, in whole or in part, my works and audio, photographs or video of me; and may reproduce them in any form, in whole or in part, and distribute them by any medium, consistent with the purposes listed above. 3. My works, and audio, photographs, or video of me, may be kept on file for an indefinite period of time and that they may be used in the future by [department or faculty member] for the purposes listed above. 4. [Department or faculty member] will not compensate me for giving this permission. 5. [Department or faculty member] is not bound to use my works, or audio, photographs, or video of me. 6. If I decide to withdraw my permission at any time, it is my responsibility to contact [department or faculty
member] and inform them of my decision in writing. 7. I hereby waive any right that I may have to inspect and/or approve the finished product or products or the editorial, advertising, or printed copy or soundtrack that may be used in connection herewith. 8. I warrant that my contribution is original and has not been published in similar form prior to the anticipated publication date of this Work, and that I am the sole author and owner of this contribution and have full power to enter into this agreement and grant the rights hereunder. If any portion of the contribution has or will have been published prior to publication on the website, I will obtain written permission for publication of these portions. If appropriate I will submit text for a credit line for any previously published material. 9. I warrant that the contribution does contain anything that is libelous; that violates any statutory or common law copyright or trademark; that violates the right of privacy or publicity, or other personal or proprietary, or any other right of any person, firm, or entity; or that contains any instruction harmful to the user. Agreed and Authorized by student: __________________________________________________________________ (Signature of Student) (Date) Agreed and Authorized by department representative or faculty member: _____________________________________________________________________________________________
__________________________________________________________________