THE STUDIUM URBIS ROME CENTER
2002 SUMMER STUDY WORKSHOP
STATEMENT OF AUTHORIZATION AND CONSENT FORM

The Studium Urbis 2002 Rome Workshop:
"Urban Reciprocity: Architecture & Urban Planning in Renaissance & Baroque Rome"
June 3 - July 8, 2002 (5 weeks)
Workshop Directors: Allan Ceen (a.ceen@flashnet.it) and Michelle LaFoe (mlafoe@mindspring.com)
http://www.studiumurbis.org

Print this form, complete it, sign it, and send it in the postal-mail to the address listed at the end of this form. Make sure to include the signed and dated Application Form and your resume/CV/professional or educational summary. Also keep in mind the length of time required for postal service delivery. If you have not received an email confirmation of its receipt within a reasonable amount of time after having mailed it, please contact us via email. We will respond to all received applications with an email confirmation of receipt (please make sure to list your email address below).

Applications received after February 16, 2002 will be processed on a space-available basis.


Name (Last, First, Middle):______________________________________________________

The following agreement is designed to protect all participants in the Studium Urbis's study abroad programs/workshops: the students, the faculty, the Studium Urbis Organization, its director, instructors, sponsors, agents, and employees, and the agencies and individuals cooperating with the Studium Urbis Organization. We require that all students and their parents, legal guardians, or spouses sign this form to indicate their agreement and permission. We require that any professionals attending the workshop sesssion sign this form to indicate their agreement and permission.

The Studium Urbis does not discriminate against individuals who have had physical, emotional or mental disorders. A medical examination is required for those programs which are physically arduous and/or when it is a requirement of the hosting institution. However, if a student has a history of any medical or psychiatric problems during the previous two years, we strongly advise that the student consult with a medical professional in their home country before departure to discuss the potential stress and difficulty of study abroad.

1. We understand that participation in the program is entirely voluntary and that any program of travel involves some element of risk. We agree that in partial consideration of the Studium Urbis Organization's sponsoring this activity and permitting the student to participate, we will not attempt to hold the Studium Urbis Organization, its director, instructors, sponsors, agents, or employees liable in damages for any injury or loss to person or property the student might sustain while so participating; and we hereby release the Studium Urbis Organization, its director, instructors, sponsors, agents, and employees from any liability whatsoever for any personal injury or property damage arising from participation in the program.

2. We understand that the Studium Urbis Organization reserves the right to make cancellations, changes or substitutions in cases of emergency or changed conditions or in the interest of the group. Should the Studium Urbis Organization cancel the program, full refunds will be made unless the cancellation is due to political, natural, technological or other catastrophes beyond its control, in which case the Studium Urbis will be able to refund only uncommitted and recoverable funds.

We understand that the deposit is non-refundable. We also understand that if the student leaves the program for any reason after the balance-due payment deadline set by the Studium Urbis Organization, there will be no refund of the program/workshop fee; program/workshop fees will be refunded to the extent that prior commitments have not been made. The student should understand that by signing this agreement, he or she is obligated to pay the program/workshop fee.

3. We understand that the student as a participant in the Studium Urbis Organization abroad study workshop program is a representative of this institution during the workshop session and by signing this agreement pledges to deport himself or herself in a manner that reflects favorably on both the Studium Urbis Organization, his or her country, and himself/herself. The Studium Urbis Organization may dismiss a student from the program for behavior detrimental to the program. A dismissed student will receive no refund.

4. We understand that the program includes planned lectures, studio and/or research work, walking tours, and field trips which are germane to the educational experience, and that the student agrees to participate willingly in such activities.

5. We understand that the Studium Urbis Organization requires that all students be covered by appropriate sickness and accident insurance and that they be financially responsible for all medical expenses. In addition, we understand that payment for medical expenses customarily will have to be advanced and reimbursement sought later from the carrier.

(Name of student)_____________________________________________________ is insured under policy

number _________________________________by _____________________________________________

_________________________________________________ (insuring company), for sickness and accident

insurance. Date of policy expiration is ________________________________; in addition, the student hereby assumes responsibility for all medical expenses incurred by and on behalf of the student while participating in a Studium Urbis Organization study abroad workshop program session.

The Studium Urbis recommends that students planning to operate a motor vehicle obtain liability and collision insurance that will cover him/her in the applicable foreign country(ies). The Studium Urbis also recommends that students insure their property from loss or theft.

6. We understand that the student must make provision before departure for continuation of medical treatments such as prescriptions or special diets. No representation can be made by the Studium Urbis Organization with respect to accessibility to services and facilities abroad. Appropriate treatments, especially psychological, may not be as readily available abroad as in the United States. The director of the program should be fully informed of any special needs that have been arranged before leaving on the program.

7. In the event (I) (we) cannot be reached to give (my) (our) consent, (I) (we) the undersigned parent(s), guardian,

or spouse of _________________________________________________________, hereby authorize the Studium Urbis Organization's representative to consent for (me) (us) to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment or hospital care deemed necessary or advisable to a licensed physician during the period the student is enrolled in the Studium Urbis Organization study program workshop. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the Studium Urbis Organization to give specific consent to the diagnosis, treatment or hospital care which in the best judgment of a licensed physician is deemed advisable.

SUMMER PROGRAM
AUTHORIZATION AND CONSENT

PARENT/LEGAL GUARDIAN/SPOUSE:

I certify that I am the parent or legal guardian or spouse of the student named above; that I have read the entire preceding statement and I join in all the articles of the statement without reservation, granting my consent to all actions provided for herein.

Name of Parent/Legal Guardian/or Spouse: ___________________________________________________

Signature of Parent/Legal Guardian/or Spouse:____________________________________________

Date: _____________________________

Address (Number & Street):________________________________________________________________

(City, State, Zip Code)_____________________________________________________________________

Country: _____________________________________________

Telephone (Area Code & Number, include country code if outside the U.S.): _________________________

Email: ________________________________________


Name of Student: ________________________________________________

Signature of Student: ___________________________________________

Date: ___________________

Student's Email: ___________________________________________


The signatures of both the parent or legal guardian or spouse AND the student are required.

Submit this form and the other required information to the Studium Urbis Organization's USA contact:

The Studium Urbis Organization
Architecture & Urban Planning Workshop
c/o Michelle LaFoe, Architect & Associate
625 NW Everett, No. 344
Portland, OR 97209 USA

THE APPLICATION IS NOT COMPLETE WITHOUT THIS PROPERLY SIGNED DOCUMENT.

updated 1/2002.