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) Student Agreement (PA303) 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.
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: Witnessed by: Xavier Banner ID: 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 Rev. 7/28/2008 Form AOR105 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 1
AOR for XU Student Off Campus Overnight Intl Fac/Empee Led Rev. 7/28/2008 Form AOR105 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 : : SS COUNTY OF : The foregoing instrument was sworn to before me and subscribed in my presence this day of, 20. Notary Public 2
Student Agreement for XU Student Off Campus Overnight Intl Fac/Empee Led Rev. 12/3/2008 Form PA303 MBA 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 ) 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. 1
Student Agreement for XU Student Off Campus Overnight Intl Fac/Empee Led Rev. 12/3/2008 Form PA303 MBA 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 2
Medical Form for XU Student Off Campus Overnight International Rev. 7/28/2008 Form MED202 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: Relationship Address Name: Relationship: Address: Telephone (day): Telephone (evening): Cell Phone E-Mail: Telephone (day): Telephone (evening): Cell Phone: 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): Date: Printed Name of XU Student: 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. 1
Medical Form for XU Student Off Campus Overnight International Rev. 7/28/2008 Form MED202 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 (LAST NAME) (FIRST) (MIDDLE) (BIRTH DATE) ( ) Male ( ) Female 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 Epilepsy/convulsions High blood pressure Ulcer/stomach problem Heart problems (describe) Jaundice/hepatitis Protein/sugar in urine Surgery (TYPE AND YEAR) 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. 2
Medical Form for XU Student Off Campus Overnight International Rev. 7/28/2008 Form MED202 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. 3
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: