Appendix V
Student Financial Authorization and Release
Background
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East Tennessee State University offers its students opportunities for international study
through various course models. This Student Financial Authorization and Release (“Release”)
applies to the faculty-led course model.
Your faculty and/or course leader serves as liaison between the University and the various
third party providers involved, such as travel vendors, tour operators, host institutions, etc.
(“third party providers”). This allows the leader to coordinate the course and itinerary for
activities related to the course, and typically to obtain better values by securing group rates.
In order to facilitate the agreements between these third party providers, the University has
agreed to accept monies from you and pay the same on your behalf to the third party
providers.
The terms below set forth the terms by which the University will accept your payments for
your study abroad course and pay them to the third party providers.
For and in consideration of my participation in a study abroad course sponsored and led by East
Tennessee State University (“Course”), I hereby agree to the follow terms:
Authorization
1. I hereby authorize East Tennessee State University (“University”), through its employees, agents
and representatives to pay any and all third parties associated with the Course, including
payments to third party providers, loss of deposits, partial refunds, and reasonable changes in
proposed lodging accommodations, travel and meals, as the same are deemed advisable by the
University or its representatives.
2. I understand that the University cannot assure travel arrangements will be without certain
disruption or alteration. I acknowledge the right of the University to make any alterations,
deletions or modifications in the itinerary and/or academic course as deemed necessary by
the University or Course leaders, as its agents. Accordingly, I acknowledge and agree to
accept all responsibility for loss or additional expenses due to such changes.
3. I agree to be responsible for course costs (travel and related expenses) as outlined in the
Course budget. I understand that course costs are in addition to tuition and fees and are
subject to a separate withdrawal and refund policy. I understand that if I leave the Course for
any reason, including illness, I will be responsible for any and all course costs, including those
assessed by third party providers.
4. If I withdraw from this course, the effective date of withdrawal and cancellation will be the
date when written notice is received by the faculty member serving as the course leader,
either in person, via campus or U.S. mail services.
5. I authorize the University to pay any and all course costs, including payments to third party
providers, with monies paid directly to the University for the Course, as well as financial aid,
scholarships, and other monies deposited in my student account. I acknowledge that a portion
of the Course budget may be designated for the support of the person(s) leading or assisting
with the Course, including, but not limited to, travel expenses and faculty salary, and I
authorize the University to pay such costs, as the same are identified on the Course budget.
June 2015
6. I acknowledge that there may be a budget surplus for the Course, and I agree that any such
surplus may be automatically carried over to the department’s budget for subsequent
courses.
7. I realize that accident and illness insurance, as well as insurance for medical evacuation and
repatriation that are applicable outside of the United States are required for my participation
in the course. I understand that a fee, set forth on the budget, will be collected to pay for
such insurance. This charge is minimal, but is required by the University whether or not I have
other medical insurance.
Release and Indemnification
I hereby release and forever discharge the University, the Tennessee Board of Regents, their officers,
employees, agents, representatives or volunteers from all rights, claims, demands and damages of any
kind, known or unknown, existing or arising in the future resulting from or related to the Program or this
Agreement.
I hereby agree that in the event that any claim shall be prosecuted against the University, the University’s
Board of Regents, the University’s officers, employees, agents, or representatives, by any third party
provider related to compensation for services provided by said third party providers for the Course, I shall
hold harmless and indemnify the University, the Board of Regents, the University’s officers, employees,
agents, and representatives from any and all claims or causes of action by whomever or wherever made
or presented for costs or damages related thereto.
I have read this release and understand it.
Signed this ________ day of ________________ 20___, at (place) _____________
Name: ______________________________________________
Signature: __________________________________________
June 2015