PREREGISTRATION
GLOBAL HEALTH EXPERIENCE REGISTRATION
Visit Department of State Travel Warnings webpage: http://travel.state.gov/content/passports/english/alertswarnings.html.
Is there a travel warning for your destination?:
No
Yes (if yes,note that CGH funds are not available to you and
that CGH strongly discourages this travel plan).
2.
Review Consular Information Sheet for Country/ies you will be visiting; pay special attention to safety and security,
crime, and traffic safety and road conditions sections: http://travel.state.gov/content/passports/english/country.html
Obtain confirmation from host site mentor or representative on official stationery or via official email (sent directly to
globhlth@mail.med.upenn.edu ), specifying the start and end dates for experience and detailed scope of activity (see notes in
student plan section regarding clinical activity)
Review all info on Center Global Health website Travel Page: http://www.med.upenn.edu/globalhealth/travel.shtml
Review CDC's Traveler's Health webpage: http://wwwnc.cdc.gov/travel/
Complete Student Health Service Pre-Travel Health Consultation Visits (schedule 3-6 months before departure)
3.
4.
5.
6.
FILL,
SAVE,
SEND
STUDENT INFORMATION AND PLAN
1.
1.
2.
complete document electronically (boxes expand & provide you with needed room), save as “[your name] GH Exp Reg”
and email as attachment to globhlth@mail.med.upenn.edu
in addition to sending as email attachment, print hard copy, sign, attach additional information required, & deliver or
mail to Center for Global Health (240 John Morgan Bldg) a minimum of 6 weeks before planned departure
Name (Last, First)
Today’s Date
Experience Location (country/town)
Email Address
Funding Source
Start Date
End Date
Status @ Time of Experience (check all that apply):
MD/PhD*
MS1
MS2
MS3
MS4
MPH
* In addition to this required Registration Form, MD/PhD students need approval for this experience from the Office of Combined Degree
& Physician Scholar Programs (an email directly to globhlth@mail.med.upenn.edu is sufficient); please attach email copy when submitting
Registration Form
Brief Description of Planned Experience (your responsibilities) & Personal Goals (250 words or less):
GH Experience Type (check all that apply):
research
public health
policy
scholarly pursuit
certificate
language immersion
clinical/low risk (without exposure to blood/body fluids policy)
clinical/high risk (potential exposure to blood/body fluids)
MS1/2and MPH students are not approved for clinical experiences that could expose them to blood or body fluids. Acupuncture and MS3/4
students interested in clinical experiences (other than Penn-supervised Botswana experiences )that could expose them to blood/body fluids
must schedule a meeting with CGH to obtain approval for plan before proceeding.
Relevant Language Skills & Previous International Experience:
Emergency Contact: Name, Relationship, Phone, Cell/Mobile, Email Address
Host Organization
Website Address
Mailing Address
Mentor/Supervisor Name
Title
Phone #
Email
Checklist of Registration Requirements & Acknowledgement of Student Obligations
completed everything in pre-registration box at top of this form
official mentor/supervisor email/letter to globhlth@mail.med.upenn.edu attached to this registration form
Pre-Travel Student Health Service (SHS) Consultation Form attached
prescriptions provided by SHS filled
passport and all visa/country entry documents obtained
reviewed the scope of personal health insurance coverage and obtained additional coverage as needed
Penn Global Activities Registry (http://www.upenn.edu/globalactivities/ ): travel plans entered; screenshot showing flight info attached
printed ISOS member/contact information to keep at hand throughout travels http://www.med.upenn.edu/globalhealth/travel.shtml#isos
registered travel plans online with the Department of State: https://step.state.gov/step/
I have completed all activities specified above. In addition, I agree that:
1.
2.
If I am an MS1 or MS2 student, I will not engage in any clinical activity that could expose me to blood and/or body fluids. If I
am an MS3 or MS4 student who may be exposed to blood and/or body fluids while pursuing an opportunity other than those
arranged through the Botswana UPenn (Infectious Disease) Partnership or the Indian Health Service, I was obliged to schedule a
meeting with Center for Global Health before my first visit to Student Health Services to discuss obtaining approval for my
plans. In addition, I have attached a completed and signed Clinical Plan Agreement.
Within 1-2 weeks of returning from my global health experience (GHE), I will complete and submit the Center for Global Health
Questionnaire/Report form and the Registrar’s GHE Evaluation, and that I will reconcile any travel advance received.
I understand that, as a Penn Medicine student, these are my professional obligations.
Student Signature
Date
NOTE: SCROLL DOWN TO COMPLETE AND SIGN REQUIRED RELEASE/WAIVER AND PEP FORMS
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Penn Medicine/ Center for Global Health / globhlth@mail.med.upenn.edu
rev 08 25 2015
INTERNATIONAL EXPERIENCE RELEASE AND WAIVER OF LIABILITY FORM
(please initial each paragraph to confirm that you have read it carefully and sign at the bottom of this page)
In consideration of my participation in the international experience described on previous page(s), I, the undersigned student,
acknowledge and agree to the following conditions:
Although the University of Pennsylvania School of Medicine (“the University”) and/or the sponsor of the experience have taken
reasonable steps to provide resources and guidance, I understand that my participation in the experience may expose me to
significant risks, including, but not limited to, crime, terrorism, war, exposure to communicable diseases, the hazards of travel by
airplane, vehicle and foot, serious bodily injury or death, property damage and other risks that may not be foreseeable. I recognize
that the University cannot guarantee my safety and I understand that I am solely responsible for my safety and I assume
responsibility for all risks associated with my participation in the experience. _______
I know that I am not required to participate in this experience in order to satisfy any requirements of the University of Pennsylvania
or the School of Medicine, even though this experience may be an approved part of my education. Furthermore, I recognize that if I
am required to leave or if I decide to leave before its conclusion, there is no guarantee that I will receive any approved academic
credit or reimbursement of any payment made for this experience. If I have received funds for this experience, I may be
required to return them. _______
I understand and accept that, as a participant in the experience, I am required to observe the laws of the country in which I will be
residing and all academic and disciplinary regulations in effect at the host institution. I further understand and accept that while
participating in the experience I will remain enrolled concurrently as a degree candidate at the University of Pennsylvania and, as
such, I agree to adhere to the University’s Statement on General Conduct and Code for Academic Integrity. I also understand
that my behavior impacts on the reputation of the University of Pennsylvania and that poor behavior could result in a loss of
opportunity for future students. I realize that violation of the foregoing and/or academic failure or disciplinary disturbances may
constitute grounds for my expulsion from the experience and referral of any violations to the Student Standards Committee.
_______
I am informed that the University strongly recommends that students studying abroad have insurance coverage valid overseas to
protect against the costs of hospitalization and medical care in the event of sickness, accident, disability, or death, and to offset
expenses of unexpected emergency evacuation and repatriation, trip cancellation, or loss of property. I understand that I am solely
responsible for obtaining Travel and Health Insurance for myself. _______
I understand that acquisition of a mobile phone which allows me to place and receive emergency calls while out of the
country is required. Once obtained, I will provide # to emergency contact/s, State Department, and Intl SOS. _______
I confirm that I have been advised to consult the U.S. Department of State resources for information regarding travel to the country
in which the experience will occur. I have been instructed to pay special attention to safety and security, crime, and traffic
safety and road conditions sections and I have made the decision to participate in this global health experience after reviewing this
information. I further understand that the School of Medicine does not support activities in countries where a State Department
Travel Warning exists and that the School of Medicine is, in fact, strongly opposed to such activities. _______
I agree to participate in any orientation required for the experience; to pursue the necessary steps to obtain required authorizations in
the country in which the experience will take place if my participation in the experience requires such authorization; and to obtain
medical travel advice and immunizations appropriate for any country in which travel is planned. _______
I understand that the University of Pennsylvania, including the School of Medicine, accepts no responsibility for any delay, loss,
damage or injury to person or property caused to others or me whether prior to departure, during travel or while participating in the
experience abroad. Further, the University shall not be responsible to any person for any of my acts or omissions, except to the
extent that my activities are within the scope of approved activities covered under the University’s general liability insurance.
_______
I agree to hold harmless, release and forever discharge the University and its trustees, officers, employees and agents from any and
all claims, demands and causes of action of whatever kind that I may have including, but not limited to, illness, bodily injury,
imprisonment, death and loss or damage to property, or the consequences thereof, resulting from or in any way connected with my
participation in the experience. _______
My participation in this experience is voluntary, and I freely agree to the stipulations of this waiver. By signing below, I certify that
I am at least 18 years of age and that I have carefully read this Release and Waiver of Liability, understand it, and agree to be
legally bound by it, that I have fulfilled the checklist requirements on the previous page(s), and that all of the information I have
provided in this form and in all attachments is accurate.
Signature
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Penn Medicine/ Center for Global Health / globhlth@mail.med.upenn.edu
Date
rev 08 25 2015