Study Abroad Release And Waiver Of Liability Form (Page 3 of 3) in pdf

Study Abroad Release And Waiver Of Liability Form Page 3

STUDY ABROAD RELEASE AND WAIVER OF LIABILITY FORM

Information obtained from US Department of State, US Centers for Disease Control, and

World Health Organization(State Department and CDC required; WHO is optional)

Name of student: _________________

Country of Travel/Work: _________________________

I have consulted the following organizations regarding travel advisories to the above listed country.

U.S. State Department:

Telephone # 202-647-5225

Internet:

Date of State Department contact: ______________

Information obtained:

_____________________________________________________________________________________

CDC:

Telephone: hotline 877-FYI-TRIP. Inform: 888-232-3299

Internet:

Date of CDC contact: ________________

Information obtained:

_____________________________________________________________________________________

WHO:

Internet:

Date of WHO contact: ________________

Information obtained:

_____________________________________________________________________________________

Please return this form to the Office of Academic Programs, School of Medicine, University of

Pennsylvania.

Study Abroad Release And Waiver Of Liability Form Page 3