Office of International Services
UTHSCSA STUDY ABROAD PROGRAM
ASSUMPTION OF RISK AND RELEASE FORM
Name of Study Abroad Participant: _______________________________________________________________
Date of Birth: ___________________ Student Number: __________________________
Study Abroad Program Name/Location: ___________________________________________________________
In consideration of the opportunity to participate in a UTHSCSA STUDYABROAD PROGRAM, I hereby agree as follows:
1. Risks of Study Abroad. I acknowledge that participation in the University’s Study Abroad Program specified
above (“the program”) involves risks not found in study at the university. These risks include but are not limited
to those involved in traveling to and within, and returning from, one or more foreign countries; foreign political,
legal, social, and economic conditions; different standards related to transportation and the movement of
people, safety and maintenance of buildings, roadways, public places and conveyances; local medical and
weather conditions; use of language other than English; and other matters described on a separate U.S. State
Department Travel Advisory and/ or a Program Risk form, which I have received, reviewed, and initialed, and
which is incorporated by reference in this release form. By my signature herein and by my participation, I attest
that I have made my own investigation into the program and am willing to accept these risks.
2. Institutional Arrangements. I understand that the University does not represent or act as an agent for and
cannot control the acts or omissions of, any host institution, host family, transportation carrier, hotel, tour
organizer, independent contractor or other provider of goods or services involved in the program. I understand
that the University is not responsible for matters that are beyond its control. I hereby release the University, its
officers, employees, and agents from any liability resulting or arising from any injury, including injury of a fatal
nature, loss, damage, accident, delay, or expense associated with any such matters. INITIAL:_______
3. Independent Activity. I understand that the University is not responsible for any injury, including fatal injury or
any loss I may suffer when I am traveling independently or an otherwise separated or absent from any
University- supervised activities. INITIAL:_______
4. Health and Safety.
A. I acknowledge that I have been advised to consult with a medical doctor with regard to my personal medical
needs and about the location(s) where the Program is to be offered. I hereby confirm that there are no
health- related reasons or problems that preclude or restrict my participation in this Program.
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 Program. I recognize that he
University is not obligated to attend to any of my medical or medication needs, and I assume all risk and
responsibility therefore. If I require medical treatment or hospital car, in a foreign country or in the United
States, during the Program, the University is not responsible for the cost or quality of such treatment or
care. I have or agree to procure adequate insurance to cover emergency medical needs and evacuations or
repatriation necessary.
C. The University may (but is not obligated to) take any action it considers to be warranted under
circumstances regarding my health and safety including sending me home from the location of the Program.
Should this occur, I agree to pay all expenses relating thereto and release the University from any liability for
an actions in this regard.
5. Program Changes. The University has the right at any time to make cancelations, substitutions or changes in
case of emergency, circumstances of unrest, war or conflict or acts of terrorism or changed conditions or in the
interest of the Program. I understand that the University’s fees and program charges are based on current
airfares, lodging rates, meals and service cost, and travel costs, which are subject to change. If I leave or am
expelled from the Program for any reason, there will be no refund of fees already paid. I accept all responsibility
for loss or additional expenses due to delays or other changes in the means of transportation, other services,
weather, strikes, or other unforeseen causes. If I become detached from the Program group, fail t o meet a
departure bus, airplane, or train, or become sick or injured, I will, at my own expense, seek out, contact, and
reach the Program group at its next available destination. INITIAL: _______
Knowing the risks described above, and in consideration of being permitted to participate in the Program, I
agree, on behalf of my family, heirs, and personal representative(s), to assume all the risks and
responsibilities surrounding my participation in the Program. To the maximum extent permitted by law, I
release and indemnify the Board of Regents of the University of Texas System, and its officers, employees and
agents, from and against any present or future claim, loss or liability for injury to myself, including fatal injury,
or property which I may suffer, or for which I may be liable to any other person, during my participation in the
Program (including periods in transit to and from any country where the Program is being conducted). I have
carefully read this Release Form and incorporated U.S. State Department Travel Advisory and/ or Program
Risk Form before signing below. No representations, statements, or inducements, oral or written, apart from
the foregoing written statement, have been made.
6. This agreement shall become effective only upon receipt of my application by the University and shall be
governed by the laws of the State of Texas, which shall be the exclusive forum for any lawsuits filed under or
incident to this agreement or to the Program.
X______________________________________________________ __________________
Signature of Participant
Date
PASSPORT INFORMATION: Prior to departure, a copy of your passport information page must be provided to
1) the Faculty Advisor for the Study Abroad Program, and 2) the office of International Services!!
POSSESION, USE, OR DISTRBUTION OF ILLEGAL OR ILLICT DRUGS:
Avoid any and all possible involvement with drugs. Drug laws vary from country to country, but in many cases
they are extremely severe, regardless of whether the drug in your possession is for personal use or for sale to
others. Legal protections taken for granted in the United States are left behind when you leave the U.S. The
principle of “innocent until proven guilty” is not necessarily a tenet of legal systems abroad. The best advice is to
know the rules and laws and obey them.
U.S. EMBASSIES AND CONSULATES:
Should you encounter serious, political, health, or economic problems, the U.S. Embassies and/ or Consulates
can offer some limited assistance. They can, for example, provide you with a list of local attorneys and
physicians; they can contact next of kin in the event of an emergency or serious illness; they can provide
assistance during civil unrest or natural disaster; they can contact friends or relatives on your behalf to request
he funds or guidance; and they can replace a lost or stolen passport.
STUDENT AGREEMENT RELATED TO STUDENT CONDUCT:
A. I understand that each foreign country has its own laws and standards of acceptable conduct, including
dress, manners, morals, politics, drug use and behavior. I recognize that behavior which violates those laws
or standards could harm University’s relations with those countries and the intuitions therein, as well as my
own health and safety. I will become informed of, and will abide by, all such laws and standards for each
country to or through which I will travel during the program.
B. I also will comply with the University’s rules, standards, and instructions for student behavior. I waive and
release and claims against the university, its officers, employees, and agents that may arise at a time when I
am not under the direct supervision of the University or that are caused by my failure to remain under such
supervision or to comply with such rules, standards, and instructions.
C. I agree that the University has the right to enforce the standards of conduct described above, in its sole
judgment, and that it will impose sanctions, up to and including expulsion from the Program, for violating
these standards or for any behavior detrimental to or incompatible with the interest, harmony, and welfare
of the University, the Program, or other participants. 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 expelled, I consent to being sent home at my own expense with no
refunds of fees.
D. I will personally attend to any legal problems I encounter with any foreign nationals or the government of
the host country. The University is not responsible for providing any assistance, including the provision of
legal counsel.
STANDARDS OF CONDUCT:
Participants in a UTHSCSA Study Abroad Program are expected to 1) exhibit sensitivity to the host culture, (2) maintain
good behavior at all times, and (3) observe local rules and laws.
The University reserves the right to dismiss any participant for reasons of unacceptable personal behavior and/ or
academic participation. Such dismissal will be without refund and return transportation will be at the student’s own
expense. Such dismissal will typically result in a failing grade in the course, internship, module, or rotation.
I understand there are basic and inviolable rules of behavior related to every student abroad program:
1. Student must maintain an adequate standard of academic work in programs and behave responsibly and
appropriately in their living situation and on group excursions.
2. Students should refrain from political activity for my own safety. Students in overseas programs may not
participate in the following political activities: joining political parties or unions, demonstrations, soliciting
political material, or picketing.
3. Illegal drugs in any form are not tolerated. Foreign laws related to the possession and/ or use of illicit drugs
and/ or the possession of illegal drugs can be harsh; violation of these laws could be punishable by fine,
imprisonment, and/ or deportation. Students in a program found using possessing illegal drugs in any form are
subject to immediate expulsion from the program.
4. Violent behavior of any type will result in automatic dismissal from the program.
5. Sexual behavior that is disruptive to the program or that is offensive to the host culture similarly merits dismissal
from the program.
6. Breaches of the local laws of the host community or country will be referred to and handled by the appropriate
law enforcement authorities
I understand that as a student enrolled at the University of Texas Health Science Center at San Antonio or as a student
participating in a UTHSCSA- sponsored study abroad program, I will be viewed as a representative of the United States,
the State of Texas, my home community, and the University. It is my intention to act as a good ambassador and conduct
myself in a fitting manner. I have read these rules and I agree to follow them, and I understand that violation of this
agreement will lead to failure of the course, disciplinary sanction, academic probation, or dismissal from the University.
Signature of Applicant___________________________________________ Date________________________
Medical Self- Assessment and Emergency Contact Form
Name____________________________ Student Number___________________
It is vital for the University to have your current health information on file in case of an emergency abroad. Please
provide any changes in your health situation to the Faculty Advisor prior to and during participation in the program,
including changes in any prescription medications you may be taking. This information is not used to affect your
eligibility to participate in the Program, but will help to facilitate any necessary accommodations for your
participation. All information provided is private and confidential and will be reviewed only by University personnel
involved in delivery of the Program or its agents and who have legitimate educational or safety need to know about
your health history.
Please answer the following health questions completely and to the best of your knowledge. If you answer yes to any of
the questions, please supply details.
1. Are you currently receiving, or have you received in the past two years, counseling for the treatment of any
emotional problem, drug addiction, alcoholism, psychiatric condition or eating disorder? YES/No
IF YES _______________________________________________________________________________
2. Do you have any significant chronic medical conditions requiring on- going medical supervision and treatment,
or have you had in the past any significant condition which is currently in remission (Ex. Diabetes, heart
problem, pregnancy, cancer, etc)? YES/NO
IF YES ______________________________________________________________________________
____________________________________________________________________________________
3. Do you have any allergies (to medication, food, insects, etc.)? YES/NO
IF YES ______________________________________________________________________________
___________________________________________________________________________________
4. Are you currently taking any prescription medication? YES/NO1
IF YES ______________________________________________________________________________
____________________________________________________________________________________
5. Will you need a continuation of medical treatment while you are participating in this study abroad program?
YES/NO
IF YES ______________________________________________________________________________
____________________________________________________________________________________
6. Will you require assistance for any physical disabilities while you are participating in this study abroad program?
YES/ NO
IF YES ______________________________________________________________________________
____________________________________________________________________________________
7. Is there any additional information (concerning medical or mental health conditions or physical disabilities) that
would be helpful for the program to be aware of during your study abroad experience? YES/NO
IF YES ______________________________________________________________________________
1
If yes, you must bring adequate supply of medications for the duration of the program. It is also very important that you have a valid,
physician- issued prescription for the medication with you at the time of travel.
MEDICAL TREATMENT ABROAD DISCLOSURE STATEMENT:
 I understand that it is my obligation to seek consultation from my doctor if I have any medical condition or need
that may affect my ability to safely participate in this study abroad program.
 Having been accepted to participate in a study abroad program organized by the University of Texas Health Science
Center t San Antonio campus of the University of Texas System, I hereby authorize the Faculty Advisor of my group to
sign as my authorized agent all documents related necessary medical care (including surgery). For the purpose of this
document, this means hospital admission consent/ permission documents and any and all other documents related to
health care, interventional or surgical processes, and/or a treatment plan will be facilitated by the Faculty Advisor in the
event of any emergency via which I am or might become incapacitated. The Faculty Advisor will assist me to the best of
his/ her ability if my medical situation prevents my direct participation in the decision- making process related to my
immediate health situation.
 I also give permission for the following person(s) to be contacted in the case of a medical emergency.
 I understand that I am required to purchase and maintain study abroad health insurance and that such health
insurance will be facilitated by the University of Texas System and the UTHSCSA Office of International Services.
 I further acknowledge and agree that I will be solely responsible for all financial obligations arising from any health
care that I may receive as a result of his authorization.
 I also release and agree to hold harmless the Board of Regents of the UTHSCSA, its employees and agents, from any
liability, damages and expenses of every kind and description (including death) arising out of or in connection with the
giving of consent on my behalf for health care in the event of an emergency where my condition prevents my direct
participation. I acknowledge that the rendering of assistance as described here and on my behalf in the event of an
emergency constitutes adequate consideration for his release and hold harmless agreement.
Signature of Participant_________________________________________Date____________________
Witness Signature________________________________ Name Printed__________________________
Location of Program Abroad_____________________________________________________________
Official Departure Date_________________ Official End of Program Date________________________
EMERGENCY CONTACT INFORMATION:
Primary Emergency Contact:_____________________________ Relationship to Student_____________
Daytime Phone_(____)_________________________Evening Phone_(___)________________________
Fax Number_(___)____________________________Email: ____________________________________
Secondary Emergency Contact:__________________________ Relationship to Student______________
Daytime Phone_(___)__________________________ Evening Phone_(___)_______________________
Fax Number_(___)____________________________ Email:____________________________________