Agreement and General Release

I, * (R-MC Email Address: *), a participant (the "Participant") at Randolph-Macon College (the "College"), desire to participate in * (the "Study/Travel Course" - course number/name: *; course instructor: ). I understand that I have the opportunity to gain academic credit through enrollment in the Study/Travel Course. I realize that if I do not sign this form, and comply with all its terms, I will not be permitted to participate in the Study/Travel Course. In consideration for my participation in the Study/Travel Course, I understand and agree to the following:

1. Academic Work/Personal Conduct

  • Randolph-Macon College reserves the right to exclude any student from a study/travel course on account of unsatisfactory academic work or personal behavior. I therefore understand that students whose conduct is disruptive of a study/travel course may be sent home, at their own expense, on the next available flight. I further understand that in such cases, the student will fail the course and will not be refunded any money paid for expenses associated with the course, such as airfare, room and board, ground transportation, and entry fees.
  • The U.S. Department of State's "Tips for Traveling Abroad" web page offers this advice: "Familiarize yourself with local conditions and laws: While in a foreign country, you are subject to its laws." (source: http://travel.state.gov/travel/tips/tips_1232.html). In light of this, I understand that I am subject to the laws of the countries in which I will travel.

2. General Release from Liability

I understand, acknowledge and agree that participation in the Study/Travel Course offered through the College is not required as part of the Participant's academic or other responsibilities at the College and that the Participant's participation in the Study/Travel Course is voluntary and solely for the Participant's benefit.

  • Conduct Agreement: The Randolph-Macon College faculty instructor who is leading the Study/Travel Course (the "Instructor") has the full authority to act on behalf of the College in enforcing rules and behaviors suitable to making the educational experience worthwhile for all concerned. I acknowledge that disciplinary action may include termination of my participation in the Study/Travel Course, in addition to any action stated in FISHTALES.
  • Acknowledgement of Risk: I understand that, by enrolling in the Study/Travel Course, I am choosing to participate in the housing arrangements, excursions and social activities as coordinated by the Instructor. I acknowledge that such participation could entail a heightened risk of danger to me because of transportation to and from the off-campus/overseas locations and because of circumstances that are likely to be different from those typical on the Randolph-Macon College campus in Ashland. In order to participate in the Study/Travel Course, I am willing to assume these additional risks.

IN CONSIDERATION of the foregoing and other good and valuable consideration, the receipt and adequacy of which is acknowledged, and to induce the College to make the Study/Travel Course available for voluntary participation, the Participant freely and without reservation GRANTS A FULL AND COMPLETE RELEASE to the College and its employees, agents, successors and assigns, including but not limited to the Instructor, from any and all claims, demands, losses, expenses, irregularities, rights and causes of action, of every kind and nature, known or unknown, foreseen or unforeseen, direct or indirect, arising from or by reason of any and all bodily or other personal injuries, accidents, sicknesses, illnesses, diseases, medical treatments or any other injury or loss, including loss or damage to personal property not covered by insurance, in any manner resulting or to result from, arising out of, or in any manner connected with the Participant's participation in the Study/Travel Course, including, but not limited to (i) the Participant's air, railroad, bus or other transportation or travel resources; (ii) the Participant's receipt of medical treatment arranged or sought by the Instructor or others on his or her behalf; (iii) delays or changes in air, railroad, bus, or other transportation or travel services or hotel or lodging accommodations; (iv) any ticket or coupon issued or arrangements made for air, railroad, bus or other transportation or travel services or hotel or lodging accommodations; and (v) weather, strikes, terrorist attacks or incidents, war or other civil, national or any other violent or non-violent disturbances. The Participant further agrees that this release applies to both the Study/Travel Course and to any voluntary deviation from the course's planned activities, including, but not limited to, a decision not to return to the United States in accordance with the Course's planned return travel arrangements. The Instructor and the College do not assist students with extending their stays and that we do not track information about students' itineraries after the completion of the Study/Travel Course.

3. Informed Consent/Privacy Act Waiver

I grant Randolph-Macon College and its agents, both foreign and domestic, permission to communicate personal information about me to my parent(s) or guardian(s), or, if married, to my spouse, in the following circumstances, while I am participating in the Study/Travel Course, and offered by the college:

  • medical conditions
  • psychological conditions
  • legal problems
  • academic problems
  • behavioral problems
  • financial problems
  • missing person
  • concern about my whereabouts
Full name(s) of parent(s) or guardian(s):*

Or, if married, name of spouse:

4. Privacy Act Waiver for U.S. Department of State

  • According to the U.S. Department of State's web site: "The provisions of the Privacy Act require that U.S. citizens over the age of 18 must provide a written Privacy Act waiver before we can release information about them to third parties. This means that if the U.S. citizen you are looking for does not sign a Privacy Act waiver and agree to the release of information about his or her whereabouts, the U.S. Department of State and U.S. embassies and consulates abroad cannot release that information to you absent the applicability of one of the Act's conditions of disclosure [that is, unless one of the conditions of the Privacy Act allows release of information, without a signed waiver, to specific persons and groups and only under certain circumstances]. See the Department of State Prefatory Statement of Routine Uses Regarding Release of Records Under the Privacy Act [http://www.foia.state.gov/issuances/STATE-05.pdf]. If there is no Privacy Act Waiver, we can simply confirm whether or not we were able to contact the individual, but cannot provide other information."

In light of this information, I authorize the U.S. Department of State, including but not limited to the Overseas Citizens Services, the Bureau of Consular Affairs, and U.S. embassies and consulates abroad, to release information about me, my welfare, and my whereabouts to Randolph-Macon College and its agents, both foreign and domestic, including but not limited to the following offices:

  • Provost's Office
  • Dean of Students
  • Office of International Education
  • Campus Safety

5. Mandatory Medical Insurance

I understand, acknowledge, and agree to the importance of having medical insurance coverage while traveling abroad, and that I will be enrolled in the College's mandatory insurance plan for the duration of the Study/Travel Course under the following terms and conditions:

  • Randolph-Macon College mandates all students participating in RMC Study/Travel courses abroad to be enrolled in the International Travel Accident Insurance Plan provided through USI Affinity – Collegiate Insurance Resources (for more details, please visit: http://www.rmc.edu/Academics/study-abroad/jterm/MandatoryInsurance.aspx). The Office of International Education (OIE) will enroll each participant and distribute the insurance cards prior to departure.
  • Quoted benefits and rates are in effect through mid July and are subject to change thereafter.
  • The policy does have limitations. You cannot cancel for any reason and expect to receive your money back. However, for specific circumstances (typically medical in nature), there is a cancellation provision that allows up to $3,000 to be refunded.
  • This policy has a pre-existing condition clause, which means that if you/your child has been treated for any condition within the past six (6) months, coverage for that condition (and any related medications) is excluded and is not covered under the policy.
  • The Department of States strongly recommends that "A traveler going abroad with any pre-existing medical problems should carry a letter from the attending physician, describing the medical condition and any prescription medications, including the generic name of prescribed drugs. Any medications being carried overseas should be left in their original containers and be clearly labeled. Travelers should check with the foreign embassy of the country they are visiting to make sure any required medications are not considered to be illegal narcotics." (http://travel.state.gov/travel/tips/brochures/brochures_1215.html).

6. Cancellation and Refund Policy

Randolph-Macon College (the College) reserves the right to make cancellations, changes or substitutions to the program at any time. The College shall not be liable for any loss whatsoever to program participants as a result of changes or cancellations due to a Department of State travel warning, hostile activity, acts of war or terrorism, or in the event of social, civil unrest, a natural disaster or a similar emergency either in the U.S. or abroad. In the case of an internal unforeseen circumstance, such as health crisis of the instructor, the College will reimburse any recoverable costs of the program and make a reasonable effort to provide some form of substitution.

7. Entire Agreement

I have carefully read the content of this Agreement and General Release in its entirety and fully understand that by signing this form, I am giving up legal rights and remedies that may otherwise be available to me. I acknowledge that I have the right and opportunity to consult with an attorney or other advisor of my choice prior to signing this Agreement and General Release.

Electronic Signature:*


Date: 08-29-2015

By signing this form, you do affirm that you are the person whose electronic signature appears above and that all information provided within this form is true and accurate.

ATTENTION: You will be sent to the second of the two J-term forms upon successful completion of this form. You will also receive a copy sent to your R-MC email address.

Please note that you must complete both J-term forms before the deadline listed on the OIE web site.

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