International Programs and Services
Please carefully read and complete the Study Abroad Student Medical Information and Liability Waiver below. All fields are required.
Please email questions to International Programs and Services: firstname.lastname@example.org.
Semester and Year Abroad
Michigan Technological University international programs and activities may involve a variety of activities in outdoor settings. These may include rigorous and remote physical activities.
There is a risk associated with international activities and programs, which must be assumed by each student. He or she may incur injury as there are certain risks inherent in rigorous and remote activities.
The information gathered on this medical form is intended to help inform the program director and assistants of any pre-existing medical conditions, and to help determine if consultation with your physician is recommended prior to your taking/joining this course or program. If you have a pre-existing condition, participation in some of the activities may not be recommended. This information will be kept in strict confidence by Michigan Technological University and shared only with your permission.
Yes No Do you have health/accident insurance?
Yes No Are you generally in good physical condition? (if no, please explain below.)
Yes No Have you ever been treated or are you currently being treated for any psychological, emotional, alcohol or substance abuse problems? (if yes, please explain below.)
Yes No Do you have allergies to drugs or foods? (if yes, please explain below.)
Yes No Are you taking any medications? (if yes, please explain below.) Certain prescription medications may not be available or allowed in some countries. Research and plan ahead.
Yes No Have you had any major injuries, diseases or ailments in the past five years? (if yes, please explain below.) Certain prescription medications may not be available or allowed in some countries. Research and plan ahead.
Yes No Is there any additional information (concerning medical conditions or mental, learning, or physical disabilities) that would require accommodation or be helpful for the program to be aware of during your study abroad experience? (if yes, please explain below.)
I affirm that the confidential medical information which has been provided is accurate and complete. I understand that failure to disclose this information could affect my own safety and those around me, and I agree to hold Michigan Technological University harmless if full disclosure of a pre-existing medical condition has not been provided. In the event of illness or injury, consent is hereby given to Michigan Technological University to provide or have provided to me emergency medical care, hospitalization or other treatment which may become necessary.
I understand that parts of the course may be physically or emotionally demanding. I hereby acknowledge that I am aware of these risks and agree to follow all safety instructions and ask questions if I do not understand. I also acknowledge that, despite careful precautions, there are certain inherent risks of injury in this program, and I accept those risks. I assume the risk of any injury, disability, or death that result from any of the activities that I engage in arising out of or in connection with the Study Abroad Program.
I release and agree to hold harmless Michigan Technological University, its board of trustees, officers and employees from and against any and all damages, injuries, claims and causes of action arising out of my participation in this program or any personal or bodily injury incurred while participating in the program except only if such claimed injury arises out of the intentional misconduct by Michigan Technological University, its officers, agents or employees.