Greece 2016 Study Tour Application June 26th - July 5th, 2016
Center for Counseling and Family Studies Email your completed application to studyabroad@liberty.edu Student ID#: ________________________________ Participants may register and earn credit for one of the following courses in conjunction with the corresponding trip date. Standard tuition rates and fees will apply. Please select one of the following trip dates and the course you are interested in taking. Students may not take more than one 3 credit hour course during each study tour trip.
COUN 512 – Group Process* * Students are required to complete all prerequisites for
this course prior to the start date. The prerequisites are COUN 500, 501, 502, 504, 505, & 510.
COUN 505 – Counseling Theory and Techniques*
* Students are required to complete all prerequisites
for this course prior to the start date. The
prerequisites are COUN 500, 501, & 502.
Personal Information Last: First: Middle: Preferred Name: Date of Birth (mm/dd/yyyy): / / Email: Phone (Home): (Mobile): Home Address: City/State/ZIP: Gender (M/F): T-­‐Shirt Size: Current Degree: Have you been convicted of a felony? If so, please attach a written explanation. Marital Status: Number of Dependents: Spouse’s Name: I would like to bring my spouse on this trip. Please have the additional family member fill out an application and email it to the address listed above. Legal Name 1. Student ID (if applicable) Date of Birth Travel Information (Application can be submitted without a passport.) Email your completed application by March 31, 2016 to the address listed on Page 1
Do you have a valid passport? Country: Expiration Date: If No, have you applied for a passport? When? For more passport information go to http://travel.state.gov/passport/passport_1738.html
Date and Destination of your most recent international travel: Payment Information: All payments will be made via an LU payment portal which will be provided upon acceptance *Students must purchase flight tickets that will have them arrive before 6pm on the first day
of the trip. Athens, Greece The total cost for this trip is $1,200, which covers the participant’s in
country transportation, two basic meals (student will want to bring additional funds for snacks), lodging accommodations, museum tickets, air conditioned classroom space, an on-­‐
site Resident Director, and their LU faculty member. This does not cover airfare or course tuition. Students will be required to plan and pay for their own travel to and from Athens. There are three deadline payments which are non-­‐refundable, please check each line: Payment Deadline 1: Upon acceptance : $100 Payment Deadline 2: April 1st: $500
Payment Deadline 3: April 30th: $600 Passport Copy Deadline: April 15th (color copy emailed to application email address listed on Page 1)
Emergency Information (REQUIRED) Emergency Contact #1 (Parent/Guardian/Spouse) Full Legal Name: Relationship: Address: City/State/ZIP: Telephone: home ( ) work ( ) mobile ( ) other ( ) Email Address: Emergency Contact #2 Full Legal Name: Address: City/State/ZIP: Telephone: home ( ) mobile ( ) Email Address: Relationship: work ( ) other ( ) Email your completed application by March 31, 2016 to the address listed on Page 1
Medical Information (REQUIRED) THE FOLLOWING INFORMATION WILL BE KEPT CONFIDENTIAL. IT IS GATHERED FOR THE OFFICE TO BE ABLE TO BETTER CARE FOR EACH INDIVIDUAL. PLEASE TAKE THE TIME TO ANSWER EACH QUESTION AND FILL OUT THE INFORMATION THOROUGHLY. Allergies Foods: Drugs/Medication: Environmental Factors: Other: Medical History Current Medications (include over-­‐the-­‐counter medication, herbal products, birth-­‐control pills, etc.) Medication Dosage Reason for Taking The student is responsible for all medications that must be taken during the course of this international trip. Take care to bring the necessary medications in their original containers. Students must abide by and following The Liberty Way or Code of Honor while attending a university sponsored Study Tour. The Student Participation Agreement form is below. Please sign and date below stating that you have accurately completed this application and understand its requirements: Name: _______________________________________________ Date: _________________ Email your completed application by March 31, 2016 to the address listed on Page 1
Study Tour Participation Agreement Form Liberty University student travel programs are designed to be educational, edifying and enjoyable. It is importation that each participant is a part of all scheduled academic coursework and activities and follow the guidance of the host school site director and Center for Student Travel. Since these trips involve spending time overseas, it is important that everyone adheres to the guidelines set forth by the University. Specifically the following guidelines will apply to all participants: •
•
•
•
•
•
•
As a Liberty University Center for Student Travel Program, participants are expected to
represent the University and the Lord in a Christ-­‐ honoring manner.
While attending approved international programs, participants shall abide by the Liberty
Way or Graduate and Online Code of Honor (dependent upon classification).
Minors shall not transport alcohol as a gift in their baggage.
For safety and security, participants shall always travel in groups of at least three
individuals, at least one of whom must be a male.
To ensure the overall well being of the individual, participants feeling ill at any time
during the trip shall discuss the matter with their site director, trip leader, and/or
contact the Center for Student Travel immediately.
The Center for Student Travel and trip leader(s), through the participants Liberty issued
email account, may contact individuals both prior and during the duration of their
overseas trip. All participants must check their Liberty University email regularly and
respond to the Center for Student Travel or trip leader(s) within 48 hours.
If at any time a participant’s actions are deemed inappropriate, disruptive, or do not
conform to the mission of Liberty University, then they may be asked to return home
early at the expense of the participant.
Your cooperation and compliance is expected and appreciated. ___________________________________________________ Signature of Participant ______________ Date Email your completed application by March 31, 2016 to the address listed on Page 1
INTERNATIONAL TRAVEL ASSUMPTION OF THE RISK AGREEMENT LIBERTY UNIVERSITY 2016 Tour of Liberty University (the “Trip”). In I desire to participate in an international trip organized by Greece
___________________________ order to participate in the Trip, I agree to the terms below and assume all risks associated with my participation in the Trip, including those specifically identified below. General Risks: THIS TRIP HAS CERTAIN INHERENT RISKS WHICH MAY AFFECT ME, INCLUDING, BUT NOT LIMITED
TO, PROPERTY DAMAGE OR LOSS, TEMPORARY OR PERMANENT BODILY INJURY, SICKNESS, DISEASE,
AND EVEN DEATH. Specific risks that may be involved with the Trip include, but are not limited to: unfamiliarity with the territory, difficulty adjusting to environmental changes, language barriers, being separated from the group, unwanted contact with others, physical harm caused by other people involved with the Trip or other people at the location of the Trip, harassment (including sexual harassment), embarrassment, and emotional distress. I understand that the dangers and risks of participation in the Trip may impair my future ability to earn a living, to engage in business, social and recreational activities, and to generally enjoy life. Risks Associated with Travel: This Trip involves traveling. Traveling has inherent risks. Specific risks involved with traveling include: getting lost or separated from the Trip group or supervisors, contraction of communicable diseases, accidents, collision with other vehicles, whiplash, fires, explosions, defects in the vehicle or its equipment, blown out tires, derailments, overturning, breakdowns, running out of fuel, delays and being stranded, hazardous weather conditions, natural disasters, political unrest, kidnapping, criminal activity, terrorist activity, and conditions of locations not under the control of Liberty University. a. Additional Risks Involving Air Travel: Traveling by aircraft has inherent risks. Including the risks identified
above, traveling by aircraft has specific risks, including, but not limited to: collision with other aircraft, aircraft
contact or collision with objects such as trees, buildings, towers, poles, wires and animals, defects in the
aircraft or its equipment, hard or rough landings, turbulence, environmental conditions (including weather),
slipping and falling while boarding, aboard the aircraft or on the ground, flight preparation errors or
omissions by the pilot or crew, and illness, malady or other medical conditions resulting from or worsened by
air travel.
b. Additional Risks Involving International Travel: Traveling internationally has inherent risks. Including the risks
identified above, traveling internationally has specific risks, including, but not limited to: lack of access to
suitable healthcare, food or beverage contamination, public health problems, contraction of untreatable
diseases, unsafe local transportation and lack of facilities meeting United States disability access standards.
Risks Associated with Activities: This Trip involves activities that may be hazardous. These activities may include, but are not limited to, hiking, rafting, manual labor, skiing, snowboarding, and other recreational activities (“Activities”). Such Activities have certain and inherent risks which cannot be eliminated regardless of the care taken to avoid these risks. Specific risk that may be involved with these Activities include, but are not limited to: unwanted contact with others, negligence of others, changing environmental conditions (including dangerous and changing weather conditions), variations in terrain, slipping, tripping, falling, unhealthy sun exposure, drowning, animal and insect bites, physical exertion, difficulty walking in ski or snowboarding boots, loss of control, collisions with stationary objects like trees, equipment/tool failures, and my individual susceptibility to harm or injury (whether known or unknown to me). Participants with Disabilities: Liberty University makes reasonable accommodations for students with disabilities who are otherwise qualified to participate in its activities and Trips. However, the “Americans with Disabilities Act” does not govern accessibility standards in other countries. Liberty University does not discriminate on the basis of disability for participation in international trips, but is not responsible for assuring accessibility in international locations and cannot guarantee that accommodations will be available. In order to address this concern, Liberty University policy requires students with special needs who have been accepted into the Trip and who require accommodation to self-­‐identify their need for such an accommodation. The Director of Disability Services will speak with the student, sponsoring faculty and Trip representative to determine whether and to what extent the student’s needs can be accommodated. The self-­‐identified student may also provide documentation of disability-­‐related expenses for the Trip period to the Financial Aid Office, which may, upon review, increase financial aid eligibility. International Travel Assumption of Risk Agreement Liberty University Page 1 of 2 Third Party Actions; Personal Travel and Activities: I acknowledge and agree that Liberty University has not assumed the duty to act as a common carrier and is not responsible for the actions of any other persons, companies, or other entities that provide transportation, housing, food, medical care, or any other services to me during this Trip. I also acknowledge that if I do any personal travel or participate in personal activities outside of the Trip travel and Trip Activities, I do so at my own risk and at my own discretion. Medical Fitness & Treatment Acknowledgement: I agree that I am in sufficiently good health to participate in this Trip and that I am free from any medical condition, physical or mental, that could interfere with my ability to participate in Trip Activities or that could be worsened by participating in those activities or that could endanger my health or safety or the health or safety of other participants. If I require emergency medical treatment as a result of accident or illness arising during the Trip, I consent to such treatment. I further give Liberty University and/or its representative on the Trip authority to request medical and/or hospital treatment for my benefit in the event of any injury or sickness sustained by me while participating in this Trip. I understand that Liberty University will purchase basic travel medical insurance for me, and that this insurance will cover some of the risks outlined above, but may not cover all of them, for the duration of the Trip plus ten additional days beyond the Trip. I acknowledge that the coverage documents are available to me upon request, and that I am able to obtain any additional or supplemental insurance if I desire. Governing Law; Forum Selection: This agreement will be governed by Virginia law. Any legal action arising out of or relating to this agreement must be brought in a court sitting in Lynchburg, VA. Indemnification: I agree to indemnify, defend, and hold harmless Liberty University and its entities’ officers and employees from any liability for injuries and property damage caused in any way by me while on the Trip. Photography Consent: I hereby grant Liberty University consent to use any photograph/likeness or video of me from the Trip for marketing purposes. PARTICIPANT CONSENT (required of all participants, regardless of age) BY SIGNING BELOW, I AGREE I HAVE CAREFULLY READ AND UNDERSTAND THIS AGREEMENT, I AGREE TO ALL OF THE TERMS ABOVE, AND I HEREBY ASSUME THE RISKS ASSOCIATED WITH THIS TRIP. Signature of Participant: Name of Participant: Date: Age: Date of Birth: PARENT/GUARDIAN CONSENT (required if the participant is less than 18 years of age) I agree I have carefully read and understand this agreement, I agree to all of the terms above, both personally and on behalf of the minor participant, and I hereby assume the risk that the minor participant may be injured while participating in the Trip. I further promise to take reasonable steps to ensure the minor’s compliance with the terms of this agreement. Signature of Parent/Legal Guardian: Date: Name of Parent/Legal Guardian (Print): International Travel Assumption of Risk Agreement Liberty University Page 2 of 2