Common use of HEALTH DISCLOSURE Clause in Contracts

HEALTH DISCLOSURE. In the event of any medical emergency as determined by UIW and/or a medical provider, I hereby grant UIW and its representative’s full authority to take any action deemed necessary to protect my mental and/or physical health, at my own expense. Actions may include, but not limited to, placing me under the care of a medical doctor, admitting me in a hospital or any place for medical examination, and/or treatment. After medical attention has been administered, UIW representatives have the sole discretion to require me to return to the United States at my own expense. In the event that I return to the United States, I understand that I cannot recover any money paid for and/or in connection with the program. Should the need arise, UIW representatives are authorized to provide any personal information to any health care provider. I understand if I fail to disclose any physical and/or mental issues that may affect my full participation in the Faculty sponsored Student-club abroad program; I take full responsibility for my actions and/or inactions. Furthermore, I understand I may be asked to return to UIW, at my own expense, if my behavior and/or actions disrupt the harmony of the group, compromises the reputation of the university, and/or puts others or myself in danger. Also, I acknowledge and attest I am physically and mentally prepared to participate in activities that are typically experienced by overseas travelers, such as, but not limited to, walking longer distances compared to my home country, standing in line, sitting for an extended period of time, waiting in international airports, interacting with people from different cultures and backgrounds, and/or coping with normal stressful situations that international travelers experience during overseas travel, such as language barriers, eating different foods, observing new and different customs and practices. Please read and follow all instructions for completion. FULL DISCLOSURE REQUIRED. The information on these forms will assist health care providers in the event of a medical emergency. It is very important that this is completed fully and accurately. If a section is not applicable, enter N/A. Primary Care Physician: Office Phone: Insurance Carrier: Policy Number: Please use this space to inform UIW on your medications in use at present. Please specify special requirements if any. Do you have any drug or food sensitivities or allergies? If yes, please explain (condition, treatment). I verify all information in this health disclosure is complete, accurate and true. I acknowledge that, ultimately, I am responsible for my own physical and mental well-being. In the event of a medical emergency in which I become incoherent or incapable to make decisions, I authorize UIW representatives to take actions deemed necessary or to arrange for professional medical care on my behalf, at my own expense. In addition, I authorize UIW representatives to notify my emergency contact(s) found on this agreement. I understand providing accurate information is an important part of fulfilling my responsibilities. Signature: Date: Please read and initial each statement. Initialing each statement indicates you understand and agree.

HEALTH DISCLOSURE. In the event of any medical emergency as determined by UIW and/or a medical provider, I hereby grant UIW and its representative’s full authority to take any action deemed necessary to protect my mental and/or physical health, at my own expense. Actions may include, but not limited to, placing me under the care of a medical doctor, admitting me in a hospital or any place for medical examination, and/or treatment. After medical attention has been administered, UIW representatives have the sole discretion to require me to return to the United States at my own expense. In the event that I return to the United States, I understand that I cannot recover any money paid for and/or in connection with the program. Should the need arise, UIW representatives are authorized to provide any personal information to any health care provider. I understand if I fail to disclose any physical and/or mental issues that may affect my full participation in the Faculty sponsored Student-club abroad international program; I take full responsibility for my actions and/or inactions. Furthermore, I understand I may be asked to return to UIWbarred from participating in the program, at my own expense, if my behavior and/or actions disrupt the harmony of the group, compromises the reputation of the university, and/or puts others or myself in danger. Also, I acknowledge and attest I am physically and mentally prepared to participate in activities that are typically experienced by overseas travelers, such as, but not limited to, walking longer distances compared to my home country, standing in line, sitting for an extended period of time, waiting in international airports, interacting with people from different cultures and backgrounds, and/or coping with normal stressful situations that international travelers experience during overseas travel, such as language barriers, eating different foods, observing new and different customs and practices. Please read and follow all instructions for completion. FULL DISCLOSURE REQUIRED. The information on these forms will assist health care providers in the event of a medical emergency. It is very important that this is completed fully and accurately. If a section is not applicable, enter N/A. Primary Care Physician: Office Phone: Insurance Carrier: Policy Number: Please use this space to inform UIW on your medications in use at present. Please specify special requirements if any. Do you have any drug or food sensitivities or allergies? If yes, please explain (condition, treatment). I verify all information in this health disclosure is complete, accurate and true. I acknowledge that, ultimately, I am responsible for my own physical and mental well-being. In the event of a medical emergency in which I become incoherent or incapable to make decisions, I authorize UIW representatives to take actions deemed necessary or to arrange for professional medical care on my behalf, at my own expense. In addition, I authorize UIW representatives to notify my emergency contact(s) found on this agreement. I understand providing accurate information is an important part of fulfilling my responsibilities. Signature: Date: Please read and initial each statement. Initialing each statement indicates you understand and agree.

HEALTH DISCLOSURE. In the event of any medical emergency as determined by UIW and/or a medical provider, I hereby grant UIW and its representative’s full authority to take any action deemed necessary to protect my mental and/or physical health, at my own expense. Actions may include, but not limited to, placing me under the care of a medical doctor, admitting me in a hospital or any place for medical examination, and/or treatment. After medical attention has been administered, UIW representatives have the sole discretion to require me to return to the United States at my own expense. In the event that I return to the United States, I understand that I cannot recover any money paid for and/or in connection with the program. Should the need arise, UIW representatives are authorized to provide any personal information to any health care provider. I understand if I fail to disclose any physical and/or mental issues that may affect my full participation in the Faculty sponsored Student-club abroad international program; I take full responsibility for my actions and/or inactions. Furthermore, I understand I may be asked to return to UIWbarred from participating in the program, at my own expense, if my behavior and/or actions disrupt the harmony of the group, compromises the reputation of the university, and/or puts others or myself in danger. Also, I acknowledge and attest I am physically and mentally prepared to participate in activities that are typically experienced by overseas travelers, such as, but not limited to, walking longer distances compared to my home country, standing in line, sitting for an extended period of time, waiting in international airports, interacting with people from different cultures and backgrounds, and/or coping with normal stressful situations that international travelers experience during overseas travel, such as language barriers, eating different foods, observing new and different customs and practices. Please read and follow all instructions for completion. FULL DISCLOSURE REQUIRED. The information on these forms will assist health care providers in the event of a medical emergency. It is very important that this is completed fully and accurately. If a section is not applicable, enter N/A. Primary Care Physician: _ Office Phone: Phone Insurance Carrier: _ _ _ Policy Number: __ Please use this space to inform UIW on your medications in use at present. Please specify special requirements if any. _ _ _ _ _ _ _ _ _ _ _ _ Do you have any drug or food sensitivities or allergies? If yes, please explain (condition, treatment). _ _ _ _ _ _ _ _ _ _ _ _ I verify all information in this health disclosure is complete, accurate and true. I acknowledge that, ultimately, I am responsible for my own physical and mental well-being. In the event of a medical emergency in which I become incoherent or incapable to make decisions, I authorize UIW representatives to take actions deemed necessary or to arrange for professional medical care on my behalf, at my own expense. In addition, I authorize UIW representatives to notify my emergency contact(s) found on this agreement. I understand providing accurate information is an important part of fulfilling my responsibilities. Signature: _ _ _ _ Date: Please read and initial each statement. Initialing each statement indicates you understand and agree.