INTERNATIONAL TRAVEL REGISTRATION FORM
In compliance with UMMS travel policy, anyone traveling under the University of Massachusetts Medical School auspices must complete this travel registration form. The information provided is needed for UMass-sponsored AIG international travel insurance, which covers everyone traveling in connection to their work or study at UMMS, and to help us provide assistance should emergencies arise during travel. Upon completion of this form, you will be prompted to download and print the AIG International Travel Insurance Packet.
If your travel involves potential export control material or data, please visit the Export Control website "Do I Need a License?" Section to find out before filling out a travel registration form. * Indicates a required field
If your browser is having problems, try using UMMS supported browsers: Internet Explorer, Mozilla Firefox and Safari for Mac.
|Program Contact (Name, Title, Email, Phone, Website)*|
|Purpose and Goals of Travel (select only one)*|| |
|If other, please specify|
|Will you be doing any clinical work?*|
|If presenting or lecturing, indicate talk title(s) and/or topic(s)|
|Are you shipping or bringing with you physical goods or materials that may be subject to Export Control and Sanction laws? (See the EAR Commerce Control List.)*|| |
EMERGENCY CONTACT INFORMATION
UMMS OGH INTERNATIONAL TRAVEL LIABILITY RELEASE STATEMENT
I understand that there are dangers and risks to which I may be exposed by participating in international experiences and travel. I understand,accept, and assume any and all risks associated with these activities, including but not limited to, illness, accidents, violence, or death, all such risks being known and appreciated by me. I further understand that other countries enforce different laws, regulations or standards, including but not limited to, those relating to health, welfare, safety, crime, regulation of businesses and transportation in any form. I agree to be bound by same. As part of the consideration for participating in this program and related travel, I am fully aware of the US State Department Travel Warning and Travel Alerts, as well as the Centers for Disease Control Travel Health Notices pertinent to the country or region to which I am traveling. I have carefully considered described warnings and acknowledge that at any time warnings may become of a more urgent matter. I acknowledge that I am not required to participate in this activity and have elected to do so knowingly and voluntarily with full knowledge of all potential risks/dangers. I agree to accept, assume, and take upon myself, all risk and responsibility in any way associated with this travel and related activities. In consideration of the services, assistance, and facilities provided by the University of Massachusetts Medical School (UMMS) for these activities and travel, I agree to release, discharge, indemnify, defend, and forever save free and harmless UMMS (its Trustees, officers, employees and agents) from and against any and all liability, claims, damages, or actions (including reasonable attorney’s fees and costs) arising from and/or related to my injury, illness, or death, or damage to my property, or any other claims, actions, and disputes whatsoever, which arise from and/or relate to my travel and associated activities. I understand that this Release covers liability, claims, actions and damages that may be caused by, or result from, in part, certain acts or omissions by UMMS (its Trustees, officers, employees, or agents), including but not limited to, negligence, mistake, or failure to properly supervise and train or any other conduct by UMMS. I recognize that this Release means that I and anyone else on my behalf are giving up, among other things, rights to sue UMMS, its Trustees, officers, employees, and agents for any illness, injuries, death, damages, or losses I may incur as a result of my participation in this travel and associated activities. I understand that this Release also binds my heirs, executors, administrators, and assigns, as well as me. I have read and understand this Release, and I agree to be legally bound by its terms and conditions.