This form is required ONLY if you responded positive to any of the questions in the previous step.
Please carefully review the following rules and regulations of the Program. This agreement must be signed by the participant as well as his/her parent or legal guardian.
I, have read the AGBU Discover Armenia rules and regulations listed above and agree to abide by them throughout the duration of the program. I understand that these rules and guidelines are for the safety and the protection of the participants and staff of the Program. I further understand that if I choose to violate the rules and regulations set forth by AGBU Discover Armenia or engage in conduct that endangers the safety of my fellow participants, the Program director will take appropriate steps to stop my actions or behavior. These steps may include a verbal warning, parent notification and/or dismissal from the Program.
In the event that I am dismissed from the program due to a breach of regulations on my part, I understand that no full or partial reimbursement of the 1000€ Participation Fee will be granted to me by the AGBU Discover Armenia Program and that I will not hold AGBU responsible for any additional expenses (e.g. additional travel arrangements, etc.) that may occur as a result of my early dismissal from the Program.
I hereby release AGBU, its agents and employees from all liability, damages, causes of action, and the like during my participation in the AGBU Discover Armenia Program.
In the event that a participant wishes to withdraw from the AGBU Discover Armenia Program for any reason, he/she must inform the Program Director in writing immediately.
Cancellations prior to June 1, 2017 are subject to a non-refundable fee of 500€.
No refunds will be granted for cancellations made after June 1, 2017.
I hereby authorize AGBU Discover Armenia to release information from my medical history, including but not limited to medical records, to the relevant Program Director and to the cooperating or affiliated foreign institutions.
I understand that AGBU Discover Armenia will not request any information from my medical records unless a situation arises while I am abroad that requires information pertinent to my safety or health. I further understand that any information obtained from of my medical records that is held by the AGBU Discover Armenia will be destroyed upon the completion of my participation in the program.
I understand that, if I have a medical condition that requires or has required treatment, I must discuss my plan to go abroad with my clinician prior to my departure.
I understand that in the event that I need emergency medical care, hospitalization or surgery while participating in the program, AGBU will attempt to contact the emergency contact(s) listed on this form. In the case that my emergency contact(s) cannot be reached and an immediate decision about care or treatment needs to be made, I authorize AGBU Discover Armenia, through its representatives, to secure any necessary treatment. If coverage is not provided through my insurance program, I understand that such treatment shall be solely at my expense. I release, discharge, indemnify, covenant not so sue, and agree to hold harmless AGBU, it members, officers, agents and employees, from any liability which may result from authorizing any medical treatment and/or medication for me. I certify that all responses on this Medical Assessment and Release Form are true and accurate.
I certify that the information on this Medical Information Form is true and correct, and I will notify the AGBU Discover Armenia program hereafter of any significant or relevant changes in my health that occur prior to or during the program.
I, , have reviewed these rules with my child/minor and agree to the terms and conditions.
Signature identified by IP Address: 18.104.22.168 on Date: 27/07/2017 20:27:54.