The Pacific Rim Undergraduate Experience (Prime)

PRIME Program: Spring, Summer, Fall Quarters 2015

THE PACIFIC RIM UNDERGRADUATE EXPERIENCE (PRIME)

UNIVERSITY OF CALIFORNIA, SAN DIEGO

ACADEMIC INTERNSHIP PROGRAM (AIP)

9500 GILMAN DRIVE, 0442, LA JOLLA, CA 92093-0442

AGREEMENT OF RELEASE OF LIABILITY

Student’s Name and Permanent Address:

Name: ______

Address: ______

______

Host Site: ______

As a participant in the UCSD Pacific Rim Undergraduate Experience (PRIME) for Summer 2015, hereinafter referred to as the “PRIME Program," I hereby certify that I understand and agree with the following terms of my participation in the PRIME Program:

1.  Voluntary Participation: I have chosen to engage in this program voluntarily and of my own free will. I have been advised that I may withdraw at any time during my participation in the program for reasons affecting my health and safety without prejudice to my continued education or the academic records at my home institution.

2.  Academic Program: I understand that the purpose of this PRIME Program is academic, that I am enrolled in a demanding academic program and not on vacation, and that as a PRIME participant I am expected to be a University of California and United States ambassador of goodwill throughout the time that I study and travel abroad.

3.  Conditions of Involvement in Program: I understand that to be in good standing with the PRIME Program, I work at least four (4) hours per week during the Spring Quarter with my UCSD mentor. During the Summer quarter, I must work at least 35 hours during a week at the Host Sites. During both Spring and Summer, I must be making satisfactory academic progress as defined by the UCSD and Host Mentors.

4.  Responsibility to AIP: I will complete an Academic Internship Program enrollment form and be enrolled in the Academic Internship Program for Summer Session. I acknowledge that I will be registered via Academic Internship Program for one credit. I understand that I must fulfill the requirements of the AIP program, including completion of a reflective paper, program evaluation and transcript notation at the end of my internship. Failure to fulfill the AIP requirements will result in a grade of No Pass.

5.  Changes to PRIME Program: I understand and agree that, although UCSD will attempt to maintain the program as described in its publications and brochures, it reserves the right to change the program, including the itinerary, travel arrangements, or accommodations, at any time and for any reason, with or without notice, and that neither UCSD nor the Host Mentors shall be responsible or liable for any expense or losses that I may sustain because of these changes.

6.  Health Statement: I state that I am free of medical conditions that would endanger my life, health, or well-being while traveling or living abroad, or that would impede my ability to fully participate in all aspects of the PRIME Program. I further state that I have consulted with my medical doctor about any personal medical needs and I have described the type of work I will be doing as part of my internship. I affirm that there are no health-related reasons or problems that would preclude or restrict my participation in this program. I will follow my doctor’s advice on travel medicine, etc. and will follow the recommendations of the Center of Disease Control (http://cdc.gov/travel/), provided that they do not conflict with my doctor’s advice, in order to help ensure that I will remain healthy on the program. I agree to take any medications, as prescribed, that are necessary to stay healthy, including medicines needed to manage mental illnesses or other chronic medical conditions.

7.  Health Insurance: I state that I have accident and illness insurance coverage that is valid in all countries I will be visiting overseas during the period of the PRIME Program. I state that I also have accident and illness insurance coverage for the time periods before and after the official starting date of my education abroad program. I understand that medical emergencies may arise requiring my return to the United States or some other country (medical evaluation or repatriation). I recognize that not all medical insurance plans include these provisions automatically and will inquire to insure that I have such coverage. I state that I have or will obtain prior to departure insurance coverage for such contingencies.

8.  Authorization For Emergency Medical Treatment or Surgery: I understand that while I am enrolled in the PRIME Program occasions may arise when sickness or accident require routine or emergency medical or surgical treatment. I hereby grant permission for my submission to emergency medical care, including anesthetic, blood transfusion and surgery, during the period of the program, as recommended by medical authorities. I authorize the release of my medical records to attending physicians. I further understand that a physician or medical or surgical treatment facility often will require that some adult person be in a position to give an authorization to render the medical or surgical service, and to give reliable assurance that payment for such services will be made. Accordingly, to help ensure that I am not precluded from receiving needed treatment, I authorize UCSD and its agents and employees to obtain needed medical and surgical services for me. I agree to pay such fees and charges as may result from the provision of such medical and surgical services and to reimburse UCSD, it agents and employees, for any fees or other expenses it or they might reasonably incur should it or they be required to pay any such fees or charges or other costs incident to the provision of such services. Also, I desire to assure UCSD that I will pay the charges for such services that may be arranged for by UCSD, or the PRIME Program Director, if my medical insurance does not fully cover all such charges. I also understand that normally UCSD will notify my emergency contact in advance of any unusual medical or surgical procedure that may be required, but agree that no such advance notice is expected unless it may be practically and conveniently given.

9.  Emergency Contact Person (parent or other while you are abroad):

Name:______

Address:______

Phone:______

10.  Information Release: In the event of any emergency during the time that I am a participant in the PRIME Program (for example if I should suffer any physical injury or other threat for my mental or physical well-being) I hereby give permission to representatives of UCSD and this program to notify the following named persons of my whereabouts and/or my condition:

Name:______Relationship:______Phone:______

Name:______Relationship:______Phone:______

Name:______Relationship:______Phone:______

11.  Pre-Departure Responsibility: I agree to read pre-departure information and references provided by the program, including but not limited to the section on health, safety and security abroad in "Go Global!" (http://icenter.ucsd.edu/_files/pao/pre-departure/gs/Go_Global.PDF) and the "Steps to Going Abroad" (http://icenter.ucsd.edu/_files/pao/pre-departure/oap/OAPProcedures.pdf) checklist. I take full responsibility for following the precautions and instructions, including acquisition of adequate health insurance, as described in the above-mentioned materials and on the U.S. State Department Travel Advisories, located at http://travel.state.gov/travel/cis_pa_tw/tw/tw_1764.html. The U.S. Department of State’s hotline for American Travelers is (202) 647-5225.

12.  Passport and Visas: I understand that I am responsible for obtaining both a passport and a visa for the host country. I further understand that I will not be accepted into the program without a valid passport (or one that has been applied for). Finally, if I do not obtain a visa 3 weeks prior to departure, I may not be able to participate in the program.

13.  Individual Safety and Welfare: I understand that while representatives of the PRIME Program will make every effort to assist me in the event of emergency, responsibility for my safety and welfare is mine alone. I am aware that the Academic Internship Program Office and the Programs Abroad Office recommend in orientation programs and in written pre-departure materials that I register with the U.S. Embassy or Consulate in my host country, and that I take a variety of actions to avoid illness, injury, crime, terrorism, political disruption, and war.

14.  Codes of Conduct: I understand that I must act responsibly and ensure that my behavior will not endanger me or others. These requirements are necessary to ensure the safety and well-being of all program participants, the faculty, and others in the community, as well as to ensure the continued viability of the program. The PRIME Program participants

a.  Agree to comply with the UCSD Principles of Community and Student Code of Conduct, the code of conduct established by my Host Site, and by all laws of my host country/countries

b.  Must be familiar with and abide by the terms of this Agreement, with materials provided during enrollment, with University, campus, host institution, and residence rules, regulations, and standards of conduct for students, and with program participant handbooks and guides;

c.  Must at all times respect the laws, customs, and rights of people in all countries visited, and must not engage in illegal, dishonest, disruptive, or dangerous conduct that jeopardizes the safety and well-being of themselves or others; and

d.  Must avoid conduct that jeopardizes the orderly operation of, and the educational opportunities provided by, the PRIME Program, and/or the standing, credibility, and viability of the UC San Diego as a whole.

15.  Breach of Agreement: I understand that if I breach this agreement, the PRIME Program Directors may take appropriate action, up to and including immediate removal from the program. I acknowledge that, because of the exigencies of foreign travel and the lack of administrative resources on site, my rights with respect to any alleged breach of agreement are controlled solely by the terms of this agreement.

a.  I understand that the decision whether I have breached the agreement and what action is appropriate is within the sole discretion of the host faculty mentor, the UCSD mentor in consultation with the Program Directors. This includes whether or not I can stay and continue to participate in the program and stay in the housing facilities

b.  I understand that breach of this agreement may result in

i.  immediate permanent removal from the program and exclusion from facilities, activities, and/or events. The program will not be responsible for a participant’s expenses if he or she is removed from the program.

ii. temporary exclusion, in whole or in part, from the program or from all or specified classes, facilities, activities or events; and/or from the host institution and host housing.

iii.  written warning from the PRIME Director.

c.  I understand that student disciplinary procedures do not apply to removal or exclusion from the PRIME Program for breach of agreement. Before removing and/or excluding a participant from the Program for a breach of agreement, the Host mentor and Program Directors will, if possible and practicable under the circumstances, meet with the participant to provide notice of the nature of the suspected breach and give the participant an opportunity to respond. The Program Directors determination after meeting with or attempting to meet with the participant is final.

16.  Examples of Breach of Agreement : I understand that a breach of this agreement includes, but is not limited to, the following:

a.  Any behavior that endangers the health or safety of the participant or others, including, but not limited to physical assault, threats of violence, or other conduct that threatens health or safety.

b.  Any behavior that is detrimental to the learning process and academic purposes of the program, including but not limited to academic misconduct (see “Code of Academic Conduct” — http://students.ucsd.edu/student-life/_organizations/student-conduct/index.html), and/or which causes non-trivial disruption to the program, to the host institution, or to facilities, activities, or accommodations (including host families and their homes).

c.  Any possession, distribution, or use of illegal substances, or possession, distribution, or misuse of alcohol, including but not limited to

i.  intoxication or other use or misuse of alcohol or other controlled substances that disrupts PRIME Program programs, or facilities; or

ii. endangering a fellow participant who is using/under the influence of alcohol.

d.  Any possession, distribution, or use of weapons any kind (including but not limited to firearms and knives) in or at PRIME Program’s facilities, or activities. PRIME Program will immediately terminate the agreement of a participant who attempts to use a weapon of any kind.

e.  Any behavior that endangers property or resources of others, or which jeopardizes the viability of the program, including but not limited to

i.  theft, misuse or damage to or destruction of facilities, equipment (including computers, email accounts, and other electronic resources), or property of the program, of other participants, or of other individuals in the community; or

ii. forgery, alteration, or misuse of official documents, records, keys, electronic devices or identification, including identity theft or credit card fraud.

f.  Any failure to comply with University Standards of Conduct, PRIME Program rules, terms and standards of this agreement, or other rules or regulations of the host institution or residence facility, all of which are incorporated herein by reference;

g.  Any failure to participate in the program as determined by the Faculty Leader (e.g., failure to work with the UCSD or host mentor or his/her team, failure to participate in required events or activities, failure to submit academic work, or disruption of activities, etc.); and/or

h.  Any failure to provide PRIME Program with complete and accurate personal information as requested, or to provide updated information if there are any changes. Personal information includes, but is not limited to my current, permanent, and mailing addresses and phone number; my parent, guardian, and/or emergency contact name, address, phone number, and email; my current health condition and requested medical history; and my email address.

17.  Referral for Student Disciplinary Action. I understand that, in addition to and separate from remedies

for breach of agreement described under number 11 above, I may be referred for student disciplinary

action at UCSD. The Faculty Leader may refer PRIME participants for disciplinary action by sending a

written referral to the UCSD Student Policies and Judicial Affairs (SPJA). SPJA will notify the participant