Acknowledgement and Waiver of Liability

  • [ 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.

  • Student's Signature

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  • Student Information

  • Elective Information

  • Date Format: MM slash DD slash YYYY
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