Acknowledgement of Risks and Responsibilities
For a printable version of this form see under "forms" on the Laurier International website
I am aware that during the exchange program/ work/ study/ field-trip/ research/ service abroad program in which I am participating, certain risks and dangers may occur, including, but not limited to, the hazards of traveling, accidents, natural disasters (act of God) or illness. I understand that Wilfrid Laurier University (“Laurier”) is not able to ensure my safety from such risks and dangers.
I acknowledge that I am not an insured person or covered under any policy of insurance held by Laurier in the event of death, injury or loss (including loss of property) while I am engaged in these activities (See Note). If I wish to have such insurance coverage, or additional health insurance, it is my sole responsibility to acquire it. I acknowledge that I have been provided with information on available additional health insurance. It is also my responsibility to notify my provincial Ministry of Health and/or other provincial agencies (in Ontario this is OHIP), if I will be out of the province for more than seven (7) months.
I acknowledge that I am responsible to research into the location I am going to and affirm that I understand what is required concerning medical, health, wellness, safety, legal and cross-cultural considerations for preparing for a trip abroad. I acknowledge that prior to departure I have:
o attended a Pre-departure Session hosted by Laurier International or the Department with which I am affiliated
o completed all pre-departure training as required by my affiliated department
o completed the DepartSmart program in its entirety
o registered on-line for the Registration of Canadians Abroad (www.voyage.gc.ca)
o been advised of various aspects of international travel, potential risks and dangers, as well as the need to act in a responsible manner at all times.
For my personal security, I acknowledge I should:
o respect the laws and the customs of the host country
o complete a pre-departure physical and any required immunizations
o avoid participation in activities in opposition to the government of the host country
o follow any directive issued by the Canadian Government, the granting agency or Laurier University
o take all reasonable protections to ensure my personal welfare
o monitor DFAIT Travel Reports for my particular host region
Further, I acknowledge that I have read the excerpt on Student Code of Conduct (12.2) taken from the current Laurier Undergraduate Calendar here. In particular, I acknowledge that I am expected to abide by the policies, procedures and practices of the university/ agency where I am studying or working; and that I am solely responsible for all expenses (accommodation, phone/fax/email, transportation, etc) relating to my stay at the university/ agency, unless otherwise arranged.
I have fully informed my designated emergency contact person regarding all aspects of this program, including the nature of possible risks.
Signature: ___________________________ Name Printed: ________________________________
Note: All Laurier students must be covered by a provincial health care plan, UHIP, or an approved equivalent plan to UHIP. This provides coverage for physician and hospital expenses up to the varied maxima of these plans. In addition, Laurier students are required to participate in the StudentWise Health and Dental Plan which, upon application, includes up to 150 consecutive calendar days of out-of-Canada coverage. Students however, can declare equivalent or superior coverage and opt out of the StudentWise Health and Dental Plan. My signature above indicates that I have checked my out-of-Canada coverage under the StudentWise Health and Dental Plan or an equivalent plan and consider it to be appropriate for the risks I know I will be facing.
Purpose of travel: Academic Exchange □ Co-op Work Term □ Research □ Other □ _______________________
STUDENT IS RESPONSIBLE FOR RETURNING SIGNED FORM PRIOR TO DEPARTURE TO THE INTERNATIONAL ACTIVITY CO-ORDINATOR RESPONSIBLE