[ If you are a B.U. medical student who will be undertaking
a global health, B.U.-sanctioned activity, you are required to read and sign
the following acknowledgement and waiver of liability before departure. Global
health activities include (but are not limited to): 1) clinical electives abroad
(4th year); or 2) summer global health experiences (between first and second
year). ]
I would like to participate in the Global Health Program elective/activity
indicated on this form (below). This is an optional, elective, clinical activity
being offered to Boston University School of Medicine students. I recognize
that even though I will be receiving academic credit (if my participation in
this elective is approved), my participation in this particular elective is
not mandated in order to fulfill academic requirements of the Boston University
School of Medicine. My participation in this elective is a voluntary decision
on my part.
I acknowledge that I am aware that there are risks to me of injury entailed
in my participation in this elective, including the risks of travel to and from
the country where the elective will take place, as well as the risks associated
with residing in a foreign country whose level of health care and social services
may not equal those in the United States. These risks include, but are not limited
to, crime, terrorism, war, exposure to communicable diseases, serious bodily
injury or death, property damage and other risks that may not be foreseeable.
I do fully and completely assume any risks solely to myself, and accept full
responsibility for my individual physical fitness to participate in this elective
and its activities. Although Boston University will provide as much information
as possible on this elective and its activities, I also acknowledge that it
is my responsibility to review the course materials and to request further information
if needed to make a proper participation decision. I understand that Boston
University does not control or run every aspect of the elective, and the University
gives no assurances or warranties whatsoever as to the safety of participants
in this program.
In consideration of being presented the opportunity to participate in this
Global Health Program elective, and in acknowledging that I am aware of and
willing to assume the risks associated with this activity, I hereby voluntarily
agree to waive, hold harmless and indemnify the Trustees of Boston University
and its trustees, agents, volunteers and employees from any and all claims,
demands, damages and causes of action of any nature whatsoever arising out of
ordinary negligence which I, my heirs, my assigns or successors may have against
them for, on account of, or by reason of my participation in the Global Health
Program elective noted below.