*NEW* MIX Pre-Departure Form

This form is required for all UHM students going abroad on Manoa International Exchange.

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    ------------------Personal Information------------------

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    -----------------Overseas Support Needs-----------------

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    ----------------Emergency Contact Information----------------

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    ----------------Health Insurance Coverage----------------

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    -----------Release From Liability-----------

    Please carefully read the information below. 1. I, as a participant in the UHM International Exchange Program (herein referred to as “the Program”) for good and sufficient consideration, receipt of which is acknowledged, DO HEREBY WAIVE AND RELEASE all claims against the state of Hawai‘i, the University of Hawai‘i, and their agents, arising from or in any way connected with the following: a. Injury, loss, damage, accident, delay, irregularity, or expense arising from or connected with (1) the use by the Program of any vehicle or other mode of transportation or services; (2) any strikes, war, terrorism, weather, sickness, quarantine, government restrictions or regulations, act of God, or any other like reason; (3) any act or omission of any steamship or other water transport, airline, railroad, bus company, taxi service, bicycle or motorcycle, sightseeing, hotel or other lodging, restaurant, institute, school or university other than the University of Hawai‘i, or any other firm, company, individual, or agency; b. Any intentional or unintentional injury, whether or not resulting in death to me or to any other person or persons, caused, in whole or in part, by me, whether alone or together with or in association with others; c. Any intentional or unintentional damage or injury to property, whether personal, real or mixed, owned or in the custody or possession of me, or any other, caused, in whole or in part, by me, whether alone or together with or in association with others; d. Any financial and other obligations or liabilities that I may personally incur during the duration of the Program, including without limiting the generality of the foregoing, any obligations or liabilities incurred by me in any country in which the Program is conducted; and, e. Any injury or loss whatsoever suffered by me during the periods of independent travel (which I understand are unsupervised) or during any absence from the Program’s activities, be they supervised or unsupervised. 2. Agreement to Indemnify and Hold Harmless. I agree to indemnify and hold harmless the State of Hawai‘i, the University of Hawai‘i, and any of their agents, from any and all claims, costs, expenses, including but not limited to attorney’s fees, arising out of or in any way connected with any of the matters described in paragraph 1 above. 3. Health and Safety. I hereby grant, to the University of Hawai‘i and any of its agents, full authority to take whatever action 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 decision or actions as may be taken in connection therewith. I authorize the University of Hawai‘i and its agents, at their discretion, to place me, at my own (or parents’/guardians’) expense, in a hospital within or outside the United States for medical services and treatment, or, if no hospital is readily available, to place me in the hands of a local medical doctor for treatment. If deemed necessary or desirable by the University of Hawai‘i or its agents, I authorize them to transport me back to Hawai‘i by commercial airline or otherwise at my own (or parents’/guardians’) expense for medical treatment. In the event the University of Hawai‘i or its agents advance or loan any money to me or incur special expenses on my behalf while I am abroad, I (and my parents) agree to make immediate repayment upon my return to Hawai‘i. 4. Standards of Conduct. I understand that violations of the UH Student Conduct Code and/or failing to maintain required academic standing and a minimum cumulative GPA of 2.5 are grounds for disqualification from the MIX program. I will comply with the Program’s rules, standards and instructions for student behavior. I hereby waive and release all claims against the University of Hawai‘i and its agents arising at the time when I am not under the direct supervision of the Program or its agents or arising out of my failure to remain under such supervision or to comply with such rules, standards and instructions; and I agree to indemnify the University of Hawai‘i and its agents against any consequences thereof. I agree that the Program shall have the right to enforce appropriate standards of conduct, and that it may at any time terminate my participation in the Program for failure to maintain these standards or for any actions or conduct which the Program considers to be incompatible with the interest, harmony, comfort and welfare of the Program and the other students. If my participation is terminated, I consent to being sent back to Hawai‘i at my own (or parents’/guardian’s) expense with no refund of fees. 5. Alteration of Program. I understand and agree that the Program reserves the right to make cancellations, substitutions or changes in cases of emergency or changed conditions or in the interest of each group. I understand and agree that if the performance of the conditions agreements stated in the Program brochure must be altered because of war, strikes, weather, government restrictions or cancellation on part or all of the Program as the University of Hawai‘i, in its sole discretion, deems necessary, and that only those funds not actually used or committed will be refunded to me. The amount of any refund in each case shall be determined by the University of Hawai‘i at its sole discretion. 6. Visas. I understand and accept that it is my own personal responsibility to obtain all visas and documents in order to enter all countries on the Program, and including personal travel to countries outside of the Program. Further, I shall hold the University of Hawai‘i harmless in the case where I may not obtain the necessary documents for participation in the Program. I understand that the inability to obtain these visas and other documents does not constitute grounds for withdrawal with refund. 7. Insurance. I understand that as a condition precedent to my participation in the Program, I hereby agree to provide proof of coverage for medical, evacuation and repatriation insurance during the duration of my participation in the Program or to provide a statement in which I will state that all medical, evacuation and repatriation expenses that I may incur while on the Program will be the obligation of me (or my parents/guardians). I will provide this statement prior to my participation in the Program. 8. Refunds. I understand and agree that the provisions of this Agreement and Release, rather than the provisions of any other University of Hawai‘i publications, concerning cancellation penalties shall control refunds. I understand and agree that any payments for international airfare, housing payments and/or deposits, fees to the overseas university, and other pre-departure costs, are my sole financial responsibility. 9. Miscellaneous. All references in this Agreement and Release to “the State of Hawai‘i,” “the University of Hawai‘i,” “the Program,” and “its agents” shall include the State of Hawai‘i, the University of Hawai‘i, the Program, and all of their employees, volunteers, and agents. All references herein to the “parents” of the applicant shall include legal guardian or other adult responsible for the applicant. 10. Duration. I understand and agree that this Agreement and Release apply to my entire enrollment in the Program including any extensions.
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    Visit the MIX website for additional Pre-Departure Information.