Page 1 of 2 Carefully review and complete the liability form below

Page 1 of 2
Carefully review and complete the liability form below. Scan the completed form (with original
signature) to [email protected] Group Trip Leaders Only: please submit a signed liability form for
each traveler in your group.
Acknowledgement of Risks & Hold Harmless Agreement
Heightened Risk Region / Travel Warning Country
I am a University of Pennsylvania undergraduate student in ______________________
(school/college). I acknowledge that I have voluntarily and freely elected to participate in
______________________________ (international program/trip name) program which includes an
international travel to __________________________ _________________ ______________
(cities/countries) from__________________ (dates). In consideration for being allowed to participate in
this trip and for the sponsorship of my participation, I affirm and agree as follows:
1. I acknowledge that I have been made aware I am traveling to a location of heightened risk according
to International SOS and the U.S. Department of State. I have read the U.S. Department of State
Travel Warning regarding travel to and in __________________ (country) dated ________________
(month/day/year). I have also read the current International SOS Standing Travel Advice for this
country. Despite the heightened risk, I have made the decision to travel to
_____________________(country) for academic purposes during the _______________________
(semester/year) semester as a registered University of Pennsylvania student.
2. I acknowledge that my participation in the program may expose me to significant risks, including,
but not limited to, crime, terrorism, war, exposure to communicable diseases, the hazards of travel
by airplane, vehicle and foot, serious bodily injury or death, property damage and other risks that
may not be foreseeable. I understand that the University of Pennsylvania assumes no responsibility
for my safety.
5. I assume full responsibility for all risks associated with my participation in this program and, for
myself and my heirs and assigns, I agree to hold harmless, release and forever discharge The
Trustees of the University of Pennsylvania and its trustees, officers, directors, employees, and
agents from any and all claims, demands and causes of action of whatever kind that I may have
including, but not limited to, illness, bodily injury, death, and loss of personal property, or the
consequences thereof, resulting from or in any way connected with my participation in this program
and associated activities or my travel to and from ___________________ (country) unless such loss
or damage is caused by the sole negligence or misconduct of the University. I also agree that the
University shall not be responsible for my negligence or misconduct.
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6. I understand that the University reserves the right to change and/or cancel the program, including
the itinerary, travel arrangements, or accommodations, at any time and for any reason, with or
without notice, and the University shall not be responsible or liable for any expenses or losses that I
may sustain because of any such change or cancellation. I also understand that the program
organizers reserve the right to discontinue my participation in the project if my actions or behavior,
in the sole discretion of the organizer, are determined to impede or obstruct the progress of the
program in any way.
7. I certify that I have consulted with a travel medicine professional and have received information
about the specific health risks associated with my trip to ___________________ (country). I agree
to take full responsibility for procuring appropriate health insurance with international coverage
prior to my travel.
8. I have read and understand the terms of this Acknowledgement of Risks and Hold Harmless
Agreement and, by my signature below, affirm that I am at least 18 years of age and am signing it
voluntarily and with the intent to be legally bound.
Student Responsibility and Personal Conduct
I understand and accept that, as a participant in the experience, I am required to observe the laws of the
country in which I will be residing, and all academic and disciplinary regulations in effect at the host
institution (if applicable). I further understand and accept that as a degree candidate at the University
of Pennsylvania, I agree to adhere to the University’s Code of Academic Integrity and the Code of
Student Conduct. I may be asked to withdraw from my international program for violation of these
codes and/or for academic failure or disciplinary matters. I may also be asked to leave the program for
violations of my host institution’s academic and disciplinary regulations (if applicable). If I am asked to
withdraw, I am not entitled to any refund of tuition or fees. I recognize that I am responsible for any
costs associated with required withdrawal from the program and return to the U.S.
Misconduct of any kind may be referred to the University's Office of Student Conduct; students may be
subject to discipline at Penn and at the host institution.
Signature: __________________________________________ Date: ____________
Print name: _____________________________________________________________