Fall Forum Trip Waiver – Institute of Study Abroad Ireland

US. Adult - Professional Development Application Portal

Professional Development Trip Paperwork and Waivers information

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Name of your Trip

Please select your trip from the dropdown(Required)

Name of your School/Institution(Required)

Trip Start Date(Required)

Trip End Date(Required)

What is your position at your institution?(Required)

Section One - Personal Information

First Name (As per Passport)(Required)

Last Name (As per Passport)(Required)

Preferred name if different from above

Gender/Preferred Pronouns

Home Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Contact Phone Number (Home)(Required)

Contact Phone Number (Cell)

Email(Required)

Date of Birth(Required)

Please upload a recent headshot photo of yourself(Required)

Accepted file types: jpg, jpeg, png, Max. file size: 2 GB.

Name of Educational Institution(Required)

Address of Educational Institution(Required)

Section One - Personal Information (Dietary Requirements & Medical info)

Please indicate any dietary requirements.

Vegetarian, Gluten Free and Vegan meal plans are accommodated . FOOD ALLERGIES MUST BE RECORDED AND STUDENTS MUST INFORM THE DIRECTORS AND MEAL PROVIDERS ON ARRIVAL OF ANY SEVERE ALLERGIES.

Please outline any medical conditions that may be relevant: Include any details of any medications required.(Required)

Please indicate any allergies(Required)

Please indicate anything else you feel is relevant under health. All information will be treated in strictest confidence.

Section 2: Statement of Due Warning and Assumption of Risk

Voluntary Participation Agreement(Required)

I have been advised and am aware of the inherent and / or latent danger (including but not limited to: risk of serious injury, the hazards of travel, accident or illness, or acts of God) of participating in such an activity. I am aware and have been advised to have a medical examination prior to participating in this activity to ensure that I am in good physical health. I am aware that this program outdoor activities and there is a risk of accident or injury. Further, I am aware and have been advised that I must be properly covered by adequate travel insurance policy.

Program activities may include outdoor activities such as surfing, hiking, kayaking, swimming, team sports, moderate walking, options such as horseback riding, bodyboarding and other sporting activities. I understand that I am free to withdraw from any of these activities, but by participating, I have been advised and am aware of the inherent and / or latent danger (including but not limited to: risk of serious injury, the hazards of travel, accident or illness, or acts of God) of participating in such an activity.

I understand that this is a group program, and that group standards must be observed. I agree that THE INSTITUTE OF STUDY ABROAD IRELAND and the Director, Niamh Hamill shall have the right to terminate my enrolment for failure to maintain these standards, for actions or conduct which the Program and /or course director considers to be detrimental to or incompatible with the interest, harmony, comfort or welfare of the course and group as a whole. I understand that if I am asked to leave the program, I must bear responsibility for all costs including immediate return to USA. I understand that the Program and/ or course director reserves the right to change assignments and to make alterations in itineraries at any time without prior notice.

I have and do hereby note, understand, and assume all risks, which may arise from or in connection with this activity. The terms hereof shall serve as a release and assumption of risk for my heirs, executors, assigns and administrators and for all members of my family.

I voluntarily agree to participate in the Professional Development Institute of Study Abroad Ireland Program

Signature(Required)

Initials of Signee(Required)

Signature Date(Required)

Section 2: Consent Form For Emergency Treatment

Name of Emergency Contact(Required)

Emergency Contact Home Telephone Number(Required)

Emergency Contact Work Telephone Number(Required)

Emergency Contact Address(Required)

Doctor's Name(Required)

Doctor's Contact Number(Required)

Alternative Medical Contact

Emergency Consent

I consent to receiving emergency medical treatment if neccessary.

Section 3: Code of Conduct

Signature(Required)

Initials of Signee(Required)

Signature Date(Required)

Section 4: Customs and Travel Documents

Please upload a picture of your flight transcript(Required)

Max. file size: 2 GB.

Insurance Policy Number(Required)

Insurance Provider(Required)

Insurance Provider Address(Required)

Signature(Required)

Initials of Signee(Required)

Signature Date(Required)