Dr. Erin Moore Department of Anthropology
Office: KAP 340
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Anthropology 301, D Clearance, 2017
The Global Performance of Healing, Spain 2017
Please sign the following and put a hard copy under my door at KAP 340.
I shall give this to the secretary, Rita, for your D Clearance.
1. I need a copy of your passport pages with your picture.
2. I understand that I am responsible to:
1. Get a passport that will be valid for 6 months after our departure from Spain.
2. Date of expiration of my passport:______
3. Passport no. ______
4. Country of Passport:
5. If you travel on another country’s passport, then you may need a visa. It is your obligation to find out if you need a visa for a non-U.S. passport. (U.S.passport does not need a visa).
6. HEALTH: I will be required to pay for USC health insurance to cover the time of this course. coordinates this. It is about $96. for those who opted out of USC insurance. (Erin organizes this for you, You pay).
7. Due with this form. I will be required to place a $300. non-refundable deposit for the course. The University will bill you when you give me this form.
When we have other expenses before leaving (ie. trains and hotels), you will be responsible for these if you drop out before we leave. DATE: By February 1, 2017 responsible for additional expenses of trains, hotels, etc. if you drop out.
8. Are there any dates on the syllabus that you cannot make, any exceptions to the terms above?...... if yes, pls. explain below.
______
9. SURF Scholarships have been available in the past to DORNSIFE MAJORS. http://dornsife.usc.edu/surf
You may not hear until late April, last year some students got $3,000, but those with grant money for tuition or another grant received less. I can’t make you promises. I will write a letter of rec for you and provide the budget.
10. Trip Cancellation Insurance Statement I hereby acknowledge that I’ve been encouraged to purchase trip cancellation insurance as a precaution to any postponement or cancellation of the Spain PWP, Anthropology 301 course.
11. I acknowledge that I got a copy of the University refund policy.
12. The total cost of the program is approximately $3,000. If you are a Dornsife major with at least a B average you should apply to the SURF funding. From this money you will pay for hotels, trains, personal taxis, food and air travel. The university pays for Churches and Museums.
13. I will have to arrange my own housing during the length of the USC campus based classes.
Confidential Medical Information:
Do you have a required special diet (explain): ______
Allergies (drugs, food, plants (this can be a problem in Spain), asthma: ______
Medicines I am taking (besides a contraceptive): ______
Past surgeries, athletic injuries (the hike is strenuous, past injuries can give you trouble):______
Past hospitalizations: for what condition and dates: ______
Are you currently under the care of a doctor/psychologist/psychiatrist (other than yearly check-ups, birth control, or acne) ______
Have you ever taken a leave of absence from any school for any reason?
Any other information I should know about concerning your health?
Signed:
Date:
Print Name:
Printed name:
Date of Birth:
Student I.D. no.:
Phone(s):
Email:
Major:
Citizenship:
Grade level on May 18th (after Spr. Graduation):
USC address:
Health Insurance:
Emergency contact Information: of Parent or Guardian
Name,
Address,
Phone: with area code.
Background:
Travel experience: alone or with family?
I need one hard copy and one copy of this form emailed to me.
KEEP one copy for yourself.
See the deadlines for dropping the class on the website.
Sign required forms and return to me before D clearance and registration.
Required forms: Forms and more: http://dornsife.usc.edu/off-campus-programs-process/
Forms that Require Student Signatures
Know Before You Go Informed Consent Form
This document serves as a guide for students with different physical or learning abilities, those with medical conditions, and those with psychological issues in order to assist them in making an informed decision on selecting an overseas location that is appropriate for them.
Medical Treatment Authorization
This form allows USC representatives to authorize medical treatment for a student who is incapacitated and unable to make such decisions on their own.
Travel Release
This is USC’s standard release form to be used by all overseas programs. This release was prepared by the USC Office of the General Counsel. If your department wishes to include additional information on your release forms, this should be reviewed with the Office of the General Counsel before making any revisions.
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