Travel Packet 2014

WELCOME ABOARD!

Participant’s Name:     Program Name: Global Family Service Corps: TRIP 1 – GUATEMALA 2014

Return the completed packet to Ryan M. Lamberton by no later than JULY 15, 2014 Send packet in one of the following ways:1) Email: RML4@stmarys-ca.edu OR2) MAIL: CILSA at Saint Mary’sAttn: Ryan LambertonPO Box 4595Moraga, CA 94575

DO NOT TEAR ANY FORMS OUT OF THIS PACKET.

PLEASE REMEMBER:

TUESDAY, JULY 15, 2014 Deadline for full payment of remaining course fees & Deadline for getting this completed travel packet to trip leader.

YOU WILL NOT BE OFFICIALLY ENROLLED INTHIS PROGRAM UNTIL THE COMPLETED PACKET

IS RETURNED

Authorization to Release Information to your Emergency ContactTo the Participant: These persons, or a designee, are the persons to whom you are giving authorization to release the indicated information or records from your file.

Name of Participant (please print)      Program Name and Number: Global Family Service Corps: TRIP 1 – GUATEMALA 2014

Name of persons who you are authorizing to make the release:

CILSA travel party: Marshall Welch, Ph.D. & Ryan M. Lamberton

On campus CILSA representative: Jennifer Pigza, Ph.D. (Associate Director, CILSA)

College representative: Jane Camarillo, Ph.D. (Vice Provost for Student Life)

Privacy: I, the above named participant, do hereby give Saint Mary’s College of California, through the persons and program indicated above, permission to release records or information indicated below, to the person(s) indicated below. This consent is to remain in effect from AUGUST 15 th through the later of AUGUST 24 th 2014 or my arrival back into the United States.

The records and/or information to be released: Any information and records regarding any medical condition, illness, injury or medical emergency or medical evacuation record or information relating to my Global Family Service Corps travel with Saint Mary’s College of California. In addition, any information or records related to my interaction with local officials, rebels, or other third parties in the event of an emergency situation.

Please check all that apply:Orally release the informationRelease the records or information by electronic transmission Other (please specify if applicable):      

To be released to: My emergency contact listed below. For the following purpose(s): To notify my emergency contact of any medical condition, illness, injury that I sustain while attending a Global Family Service Corps trip and to inform this person of actions being taken in response to my condition.

Name of Emergency Contact:      Relationship to participant:     

Address      

Telephone Number: Home:      Work:      

Cell Phone Number(s):      

E-mail Address(es):      

Participants Signature: X__________________________________________ Date:      

THIS EMERGENCY CONTACT INFORMATION MUST MATCH THE INFORMATION ON YOUR PERSONAL INFORMATION SHEET

Saint Mary’s College of CaliforniaWaiver and Release Form for Global Family Service Corps Participants

This is a Release of Legal Rights – Read and Understand Before Signing

Name of Participant     

Date of Birth:      (If applicant is under 18 years of age, a parent or legal guardian must also read and sign this form.)

Program: Global Family Service Corps: GUATEMALA 2014

I hereby agree as follows:

1. Risks of Study Abroad: I understand and agree that participation in Saint Mary’s College of California Global Family Service Corps Program specified above (the “Program”) involves risks not found in study at the College. These include risks involved in traveling to and within, and returning from, one or more foreign countries; foreign political, legal, social, and economic conditions; different standards of design, safety and maintenance of buildings, public places and conveyances; and, local medical and weather conditions.

2. Institutional Arrangements: I understand and agree that the College does not represent or act as an agent for, and cannot control the acts or omissions of any host institution, host family, transportation carrier, hotel, tour organizer, or other provider of goods or services involved in the Program. I understand that the College is not responsible for matters that are beyond its control. I hereby release the College from any injury, loss, damage, accident, delay or expense suffered or incurred by me as a result of my participation in the Program or arising out of any such matters.

3. Independent Activity: I understand and agree that the College is not responsible for any injury or loss I may suffer when I am traveling independently or am otherwise separate or absent from any College supervised activities.

4. Health and Safety

A. I have consulted with a medical doctor with regard to my personal medical needs. There are no health-related reasons or problems which preclude or restrict my participation in this Program.

B. I am aware of all applicable personal medical needs. I have arranged through insurance or otherwise to meet any and all needs for payment of medical costs while I participate in the Program. I recognize that the College is not obligated to attend to any of my medical or medication needs, and I assume all risk and responsibility therefore. If I require medical treatment or hospital care in a foreign country or in the United States during the Program, the College is not responsible for the cost or quality of such treatment or care.

C. The College may (but is not obligated to) take any actions it considers to be warranted under the circumstances regarding my health and safety. I agree to pay all expenses relating thereto and release the College from any liability for any actions taken to assist in the furtherance of my health or safety.

5. Standards of Conduct

A. I understand and agree that each foreign country has its own laws and standards of acceptable conduct, including dress, manners, morals, politics, drug use, and behavior. I recognize that behavior which violates those laws or standards could harm the College’s relations with those countries and the institutions therein, as well as my own health and safety. I will become informed of, and will abide by, all such laws and standards for each country to or through which I will travel during the Program.

B. I also will comply with the College’s rules, standards and instructions. I waive and release all claims against the College that arise at a time when I am not under the direct supervision of the College or that are caused by my failure to remain under such supervision or to comply with such rules, standards, and instructions.

C. I agree that the College has the right to enforce the standards of conduct described above, in its sole judgment, and that it will impose sanctions, up to and including expulsion from the Program or College, for violating these standards or for any behavior detrimental to or incompatible with the interest, harmony, and welfare of the College, the Program, or other participants. I recognize that due to the circumstances of foreign study programs, procedure for notice, hearing and appeal applicable to student disciplinary proceedings at the College do not apply. If I am expelled, I consent to being sent home at my own expense with no refund of fees. If I elect not to return home immediately following any expulsion of me from the Program, I understand and agree that I do so entirely at my

own risk and cost, and that the College has no obligation or responsibility for my activities, well being, or health after the time of notice of such expulsion.

D. I will attend to any legal problems I encounter with any foreign nationals or government of the host country. The College is not responsible for providing any assistance under such circumstances.

6. Program Changes : The College has the right to make cancellations, substitutions or changes in case of an emergency or changed conditions in the interest of the Program. I understand that the College’s fees and program charges are based on current airfares, lodging rates and travel costs, which are subject to change. If I leave or am expelled from the Program for any reason, there will be no refund of fees already paid. I accept all responsibility for loss or additional expenses due to delays or other changes in the means of transportation, other services, or sickness, weather, strikes, or other unforeseen causes. If I become detached from the Program group, fail to meet a departure bus, airplane, or train, or become sick or injured, I will at my own expense seek out, contact, and reach the Program group at its next available destination.

7. Waiver and Release of Claims: Knowing the risks described above, and in consideration of being permitted to participate in the Program. I agree, on my own behalf, and that of my family, heirs, and personal representative(s), to assume all the risks and responsibilities surrounding my participation in the Program. To the maximum extent permitted by law, I release and indemnify the College and its officers, including but not limited to its trustee and regents, employees and agents, from and against any present or future claim, loss or liability for injury to person or property which I may suffer, or for which I may be liable to any other person, during or as a result of my participation in the Program (including periods in transit to or from any country where the Program is being conducted.)

8. Saint Mary’s College Financial Obligation: I understand I am not eligible to travel until my College account is paid in full. In addition, I understand that if my total academic year course load, including study abroad courses, exceeds 9.5 courses, I will be charged appropriate additional course fees.

9. Severability: I agree that, should any provision or aspect of this agreement be found to be unenforceable, that all remaining provisions of the agreement will remain in full force and effect.

10. Scope: This agreement represents my complete understanding with the College concerning the College’s responsibility and liability for my participation in the Program, and supersedes any previous or contemporaneous understandings I may have had with the College on this subject, whether written or oral.

11. Age: I represent that I am at least eighteen years of age, or, if not, that I have secure below the signature of my parent or legal guardian as well as my own.

I have carefully read this Release Form before signing it. No representations, statements, or inducements, oral or written different from the foregoing written statement, have been made. This agreement shall become effective only upon receipt of my application by the College at its offices in Moraga, CA and shall be governed by the laws of the State of California, which shall be the forum for any lawsuits filed under or incident to this agreement or to the Program.

X__________________________________________ Date       Signature of Participant

I (A) am the parent or legal guardian of the above Applicant, (B) have read the foregoing Release Form (including such parts as may subject me to personal financial responsibility), (C) am and will be legally responsible for the obligations and acts of the Participant as described in this Release Form, and (D) agree, for myself and for the Participant, to be bound by its terms. (Student should mark this section N/A (not applicable) if you are not a minor)

X_________________________________________ Date      Signature of Parent/Guardian

2014 Global Family Service Corps Participant Conduct Contract

I,       have read, understand, and agree to comply with the following requirements and conditions of behavior while traveling with Saint Mary’s College Global Family Service Corps in GUATEMALA. I understand that my participation in a travel course differs from my participation in a regular on-campus course in a number of important ways. Much of the course takes place outside of the classroom, but my actions can affect the learning environment of the course. I understand that the ability of others to learn can be markedly impaired by my behavior. I agree to act as a responsible member of the group and representative of Saint Mary’s College.

Any time my actions or behavior brings risk of disrepute to the group, or impairs the efficient functioning of the course in a material way, I will, at the sole discretion of the instructor and be sent home (at my expense).

Specifically, I agree to adhere to the following guidelines:

I agree to participate in all required program activities and meetings. I agree to be respectful of my fellow students by arriving on time and prepared for all lectures, events,

museum visits, travel departures, etc. I agree to adhere to any clothing requirements/restrictions for entrance into museums, churches, etc. I agree to adhere to any restrictions regarding the use of video equipment or cameras. I agree to demonstrate sensitivity to customs and practices characteristic of the culture I am visiting. I agree to behave in a manner befitting a student abroad and a representative of Saint Mary’s College. I agree to comply with local customs, laws, and course rules regarding drug and alcohol consumption.

(While Saint Mary’s College acknowledges the fact that most of you are of legal age for drinking alcohol in the USA, when traveling as part of a January Term group in parts of the world new to you, different rules apply. If you wish to be a participant in a January Term travel course, you must agree that the professor and no one else determines when drinking anything alcoholic is appropriate, what if anything is appropriate and how much is appropriate. This is for your welfare and that of the group since situations can arise where having your reactions or thinking slowed by alcohol even slightly can be dangerous. It can also send out the wrong message about our group.)

I agree to not endanger myself or others who I encounter while traveling. I agree to be respectful of people I encounter, places I visit and property I see. I agree to maintain a positive and cooperative attitude.

______________________________________________________________

I understand the consequences for failing to comply with the above policies and requirements.

Signature: X___________________________________ Print Name:      

Date:      

Global Family Service Corps Financial Obligation Form for 2014 Travel Program

Name:       Social Security No.:      

Program: Global Family Service Corps: TRIP 1 – GUATEMALA 2014 Trip Leaders: Ryan Lamberton & Marshall Welch

Amount paid to Saint Mary’s College of California for deposit:      

Date Paid:      

I have registered for the program listed above and have paid the 50% deposit listed above.

I understand that since Saint Mary’s College travel program require advance reservations and deposits, registration and payment of fees follow a difference schedule than non-travel programs. I agree to pay the remaining program cost as follows:

I will pay the balance (remaining 50%) of the program cost by TUESDAY, JULY 15, 2014.

Failure to pay in accordance with this payment schedule or dropping the program does not release you from the financial liability of your program. You will be held responsible for any expenses incurred by Saint Mary’s College of California prior to your dropping the program or being dropped for non-payment.

Signature: ______________________________________________________

Print Name:      

Date:      

Saint Mary’s College of California Travel Insurance FormPlease provide the following information:

First Name      

Last Name     

Program Number and Name Global Family Service Corps: TRIP 1 – GUATEMALA 2014

Male or Female     

Date of Birth     

Are you a U.S. Citizen?      

If not, Country of Citizenship?      

Social Security #      

Designated Beneficiary     

What is their relation to you?      (i.e., Mother, Father, Friend)

Primary Destination     

Date of Departure     

Date of Return     

Street Mailing Address     

City, State, Zip Code     

Phone Number     

Email Address     

Your Signature_________________________________________

Each Travel Insurance Policy provides for up to US $100,000 for Emergency Medical treatment this maximum includes Emergency Evacuation Coverage for injuries and illness, not do to a pre-existing condition. Please refer to the Patriot International Brochure for specific policy wordings, benefits and exclusions.

ACE American Insurance Company Saint Mary’s policy is zero deductible, $100,000 maximum coverage

*Participants should know that they should bring money or a credit card to pay for any medical attention needed while traveling. They will be reimbursed for these expenses (based on the coverage and exclusions listed) after completing the medical claims form and submitting it to the company. Payment comes within 30 days if all paperwork is complete.

Medical Benefits (Usual, reasonable and customary charges. Our policy is purchased with zero deductible, and no coinsurance for treatments received outside the U.S. or Canada.)

Hospital Room and Board: Up to $100,000 for average semi-private room rate

Intensive Care: Up to $100,000

Medical Expenses: Up to $100,000

Out-patient Medical Expenses: Up to $100,000Local Ambulance: Up to $100,000

Prescription Drugs: Up to $100,000

Emergency Room Illness with In-patient Admission: Up to $100,000 with additional $250 deductible

Dental – Injury Due to Accident: Up to $100,000

Dental- Sudden Dental Pain: Up to $1000

Indemnity (for U.S. citizens only): Up to $100 per night

International Emergency Care (When coordinated through the Plan Administrator, IMG)

Emergency Medical Evacuation: Up to $500,000 lifetime maximum (independent of the Maximum Limit)

Emergency Reunion: Up to $100,000

Return of Mortal Remains: Up to $100,000

Return of Minor Children: Up to $100,000

Political Evacuation: Up to $10,000

Natural Disaster: $100 per day for five days

Identity Theft Assistance: Up to $500 per Period of Coverage

Additional Benefits

Terrorism Up to $100,000 lifetime maximum

Sports & Activities Coverage: Up to $100,000 for basic sports

Sudden Recurrence of a Pre-existing Condition- Medical Up to $15,000 of eligible expenses(for U.S. citizens only):

Sudden Recurrence of a Pre-existing Condition- Up to $25,000 of eligible costs and expenses

Emergency Medical Evacuation (for U.S. citizens only):

Incidental Home Country Coverage: Up to a cumulative two weeks

End of Trip Home Country Coverage: One month for every five months of travel coverage purchased, up to a maximum of two months

Trip Interruption: Up to $5,000

Common Carrier Accidental Death: $100,000 to beneficiary, maximum of $250,000 per family

Accidental Death & Dismemberment: $25,000 principle sum

Lost Luggage: Up to $50 per item of personal property; maximum of $250 per Period of Coverage

How to Process an ACE USA Insurance Claim Form

To submit a claim to IMG, attach the receipts from the doctor, hospital, and/or prescriptions(s). Make sure there are dates written on the receipts. The claim should be submitted within 90 days for reimbursement. Here is the link to the instructions for submitting claims:www.acetravelassistance.com