Form: Student-Faculty Fellows Participation Information and Waiver

Student-Faculty Fellows Participation Information and Waiver

Everyone participating in the ASIANetwork Student-Faculty Fellows program must complete this form and waiver.

Student Name(Required)

College/University(Required)

Project Title(Required)

Project Country(Required)

Expected Project Travel Year(Required)

Faculty Mentor #1 Name(Required)

Faculty Mentor #2 Name

Gender(Required)

Full Time Undergraduate?(Required)

Citizenship(Required)

Expected Graduation Year(Required)

Academic Major(s)(Required)

Minor (if any)

Native Language(Required)

Asian Language #1

Asian Language #1 - Level of Proficiency

Asian Language #2

Asian Language #2 - Level of Proficiency

College Email(Required)

Personal Email(Required)

Cell Phone(Required)

Permanent Address(Required)

Emergency Contact #1

Name(Required)

Relationship to Student(Required)

Address(Required)

Phone(Required)

Emergency Contact #2

Name

Relationship to Student

Address

Phone

Waiver Form

ASIANetwork Freeman Student-Faculty Fellows Program

Participant Waiver

THIS IS A RELEASE--READ IT CAREFULLY

The undersigned, in applying for participation in the ASIANetwork Freeman Student-Faculty Fellows Program, hereby forever releases ASIANetwork and any officer, employee, director or agent thereof of and from any and all liability for any act or omission of any kind of character whatsoever and releases them from any costs, damages, and claims or assertions of any kind with respect to which I or my heirs, successors, or assigns may claim against them and specifically without limitation agree as follows:

I release the Program Director, ASIANetwork, and any employee, servant, agent, officer or director thereof, from any liability for injury to myself or any damage to or loss of my possessions caused by acts of omission of any hotels, carriers, fellow participants, restaurants, educational organizations, persons, groups, or organizations, including but not limited to ASIANetwork, their officers, employees, directors, agents or servants in connection with the work or study thereunder.

I have read the foregoing release and agreement and I accept the conditions stated therein.

Electronic Signature(Required)

(enter your legal name)

Date(Required)