(To be signed by student and parent, if dependent student)

Designated Program: ____________________________________________________

Program Date: ______________________________

I, the undersigned, an applicant for Eastern Michigan University's Academic Program Abroad, do waive and release all claims against the designated program and its agents, and my local school or college, for any injury, loss, damage, accident, delay or expense resulting from the use of any vehicle, any strikes, war, weather, sickness, quarantine, or government restrictions or regulations. I also release the designated program and its agents and agree to indemnify them, with regard to any financial obligations or liabilities that I may personally incur or any damage or injury to the person or property of others that I may cause while participating in the designated program, including attorney's fees and court costs.

I understand that the designated program and its agents are not responsible for any injury or loss whatever suffered me during periods of independent travel (which I understand are unsupervised) or during any absence from the university or other designated program supervised activities.

I hereby grant the designated program and its agents full authority to take whatever actions they may consider to be warranted under the circumstances regarding 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. In the event that the designated program or its agents advance or loan any monies to me or incur special expense on my behalf while I am abroad, I (and my parents) agree to make immediate repayment upon my return.

I understand that this is a group tour and that group standards must be observed. I agree that the designated program and its agents shall have the right to enforce appropriate standards of conduct and that it may at any time terminate my participation in the designated program for failure to maintain these standards or for any actions or conduct which the designated program considers to be incompatible with the interest, harmony, comfort and welfare of the other participants.

I hereby waive and release all claims against the designated program and its agents for any financial obligations or liabilities I may incur because of the termination of my participation with designated program. If my participation is terminated, I consent to being sent home at my own (or my parents') expense with no refund of fees.

I understand that in the event that I choose to cancel my enrollment or voluntarily withdraw from the program either before or during the program, I agree to abide by the terms set forth under "Cancellation Policy" in the designated program Student Handbook and the tour Itinerary/Brochure. I understand that the terms of the designated program Student Handbook and the tour Itinerary/Brochure are incorporated by reference into this agreement and it is my responsibility to read the designated program Student Handbook and the tour Itinerary/Brochure carefully before signing this agreement.

I understand that the designated program and its agents reserve the right to cancel tours, to change initial campus and advisor assignments and to make alterations in tours and itineraries as may be required. In addition, I understand that the designated program charges are based on applicable university tuition and fees, tariffs and government regulations and are subject to minor change depending upon regulations in effect at the time of departure.

I agree that it is my responsibility to meet deadlines for payment of fees and for providing passport number and/or passport, visa information and other necessary information as outlined in the tour itinerary and subsequent correspondence. I understand that failure to meet these deadlines may result in cancellation of my enrollment by the Academic Programs Abroad Office.

I have read the terms and conditions set forth in Eastern Michigan University’s Academic Programs Abroad Agreement and Release for the above designated program and understand that they constitute a part of my agreement. I further understand that this agreement shall become effective only upon acceptance of my application by Eastern Michigan University at its offices in Ypsilanti, Michigan and shall be governed by the laws of the State of Michigan and the policies, rules and regulations of Eastern Michigan University.

I will be covered by Health and Accident Insurance as follows:

Company Name_______________________________________________Policy Number_____________________

Beneficiary__________________________________________________________________________________

I certify that I am the parent or legal guardian of ________________________________, and that I have read the foregoing Agreement and Release (including such parts as may subject me to personal financial responsibility), and hereby relinquish any claim that I might have against Academic Programs Abroad or its agents (as set forth above), both on my own behalf and in my capacity as legal representative of the applicant, including without limitation any claim arising as a result of the applicant’s leaving the supervision of the designated program or at a time when the applicant has left the supervision of the designated program.

Signature of Parent or Guardian_____________________________________________________ Date______________________

Address_______________________________________________________________________________________________________

City _____________________________________________________State_______________________________Zip__________________

Phone_________________________________

Please include the following information if not provided above.

My daughter/son will be covered by Health and Accident Insurance as follows:

Company Name_____________________________________________Policy Number_______________________________