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CERTIFICATE OF INSURANCE
1) My current insurance carrier has certified that my health and
major medical insurance is currently valid to travel abroad.. YES/
NO Please circle and complete insurance inf. bellow.
2) My insurance carrier does not cover me abroad so I will be purchasing
Travel Protection Insurance: YES / NO Please circle and complete
insurance inf. bellow.
(if you have not received an application please request one)
Insurance carrier name: ___________________________
Policy # /Group #:_______________
DATES Insurance active: Address_______________________________
Tel (____)________________
I further understand that I am responsible for providing my coverage
for health, accident, major medical and hospital insurance during
the period that I will be a participant in the study abroad program
for which I have been accepted.
NAME (print clearly or type) _________________________
SIGNATURE: _______________________DATE ______
WAIVER FOR FIELD SCHOOL IN COSTA RICA LA SUERTE BIOLOGICAL FIELD
STATION FOR ALL PARTICIPANTS OR VISITORS MUST SIGN THIS FORM
(Parents must sign only if younger than 18)
I, the undersigned, an applicant for admission to the Summer Field
School in Costa Rica/Nicaragua, do waive and release any and all
claims against /La Suerte/Ometepe Biological field Stations and
its agents or its host institutions for any injury, accident, or
damages caused by a vehicle, act of war, weather, strike, sickness,
quarantine, terrorist activity, government restriction or regulation,
or stemming from any act or omission of any airline, railroad, bus,
hotel, taxi service, school, College, or other firm, agency (government
or private), company, or individual. I also release La Suerte/Ometepe
Biological Field Station and its agents and agree to indemnify them
with regard to any financial obligations or liabilities that I may
incur personally or any damage resulting from participation in this
study program. I do waive and release all claims, demands, or causes
of action against the La Suerte/Ometepe and its agents, host institution(s)
or other facilities here and abroad, for any injury, loss, damage,
accident, delay, or expense resulting from the use of any vehicle,
any strikes, war, weather, sickness, quarantine, service, hotel,
restaurant, school, College, or other firm, facility, company, or
individual.
I understand that all travel involves some risk, and I hereby agree
to assume such risk that is inherently part of foreign travel as
a condition of my acceptance and participation in the Field School.
I hereby waive and release any and all claims against La Suerte
/Ometepe and its agents for any injuries, damages, or losses incurred
in connection with terrorist activities, social or labor unrest
mechanical or construction difficulties, diseases, local laws, climatic
conditions, abnormal conditions, or developments, or any other actions,
omissions or conditions outside La Suerte and the Field School's
control. By my participation in this program, I voluntarily assume
any risks involved in such travel and presence abroad, whether expected
or unexpected. I hereby acknowledge that I have been warned of such
risks, and that I have been advised to take appropriate action and
to govern myself accordingly. I am also aware that certain insurance
companies do offer insurance against some or many of the perils
noted, and that I may opt to insure myself should I so choose.
I hereby grant La Suerte/Ometepe Biological Field Station and its
agents full authority to take whatever actions they may consider
warranted under the circumstances concerning my health and safety,
and I fully release each of them from any liability for such decisions
or actions as may be taken in connection therewith. I authorize
La Suerte/Ometepe and its agents, at their discretion, to place
me at my own (or my parent's or parents' or guardian's) expense
and without further consent, in a hospital within or without the
United States of America for medical services and/or treatment,
or if no hospital is readily available, to place me in the hands
of a local physical for treatment, should the need arise. If deemed
necessary or desirable by La Suerte/Ometepe or its agents, I authorize
them to transport me back to the United States by commercial airline
or other accessible conveyance, and I assume responsibility of the
expenses involved. Any funds advanced to me for any purpose will
be reimbursed upon demand by either myself or my parent(s) or guardian.
I have been advised that I must be covered by adequate health and
accident insurance, valid in and outside the United States of America,
during the entire period of the Field School.
I agree to comply fully with the rules of La Suerte/Ometepe and
the Field School and its agents, its host institution(s) and /or
travel companies. I agree that La Suerte/Ometepe has the right to
enforce its standards of conduct and academic integrity and that,
should I fail to comply with them, La Suerte/Ometepe has the right
to terminate my participation in the Field School with no refund
of monies paid. In the event of termination, I agree to be sent
home at my own or parent's/parents'/guardian's expense. I understand
that this is an organized program of study and that group standards
must be observed. I will comply with the rules, standards, and instructions
for student behavior. I hereby waive and release any and all claims
against / La Suerte/Ometepe Biological Field Station, the Field
School, and their agents arising out of my failure to remain under
such supervision or to comply with rules, standards, and instructions.
I agree that La Suerte/Ometepe and its agents have the right to
terminate my participation at any time for failure to maintain standards
or for any actions or conduct which La Suerte/Ometepe and/or any
of its agents deem to be incompatible with the interest, harmony,
comfort, and welfare of the other students.and academic calendar
as may be required. I understand that if program changes occur they
will not impair or weaken the goals, educational objectives, and
academic standards of the Field School.
All references to the "parent" of the applicant shall
include the legal guardian or other adult responsible for the applicant.
I have read the terms and conditions set forth in La Suerte's/Ometepe
descriptive information on the Summer Field School in Costa Rica/Nicaragua,
and I agree that these constitute a part of my agreement with the
Field School. I understand and agree to all of La Suerte's/Ometepe’s
terms as set forth in the descriptive information and in this Release.
I further understand that this agreement shall take force only upon
my acceptance into the Summer Field School by the La Suerte and
its agents.
Signature of Applicant: ___________________Date:_______
Name (print clearly or type)______________________
I certify that I am the parent or guardian of the above signed applicant,
and that I have read the foregoing release and examined the information
in the program description. I hereby join in each and every part
of the Release (including such parts as my subject my to personal
financial responsibility), and hereby relinquish any claim that
I may have against La Suerte/Ometepe Biological Field Station or
its agents (as set forth above), both in my own behalf and in my
capacity as the legal representative (as applicable) of the applicant,
including without limitations any claim arising as a result of the
applicant's leaving the supervision of La Suerte's /Ometepe and
its agents.
SIGNITURE of PARENT/guardians required only for students who are
under 18 year of age:
(Father)________________________________ Date:________
Name (print clearly or type)_______________________________
(Mother)________________________________ Date:________
Name (print clearly or type)______________________________
TEL (Father)_____________________________________
TEL (Mother) ______________________________________________
Email (Father)____________________________________
Email (Mother)_____________________________________________
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