Colorado School of Mines International Travel Registration

For Undergraduate and Graduate Students

Contact Information

First and Middle Name(s) (as on passport)

Last Name(s) (as on passport)

CWID

Mines Email

Phone

CISI International Insurance

Mines has partnered with Cultural Insurance Services International (CISI) to provide international health insurance to students who are traveling internationally. You are required to obtain CISI insurance (using a valid credit card) for the entirety of your international travels. Price rates are as follows:

• Trips up to 2 weeks in duration: $24.50

• Trips over 2 weeks in duration: $49.81/month

Follow this link to purchase CISI.

After you purchase CISI insurance, you will received confirmation of your plan and a policy number. Please enter your policy number below. If you have any questions about CISI insurance, feel free to email abroad@mines.edu and we can provide more information/materials.

Individual CISI Identification Number

Please write in your individual identification number (23XXXXX). DO NOT write in the group policy number (19 GLM N16816826) as this number is the same for everyone.

Emergency Contact Information

Emergency Contact First Name

Emergency Contact Last Name

Relation to Traveler

Emergency Contact Email

Emergency Contact Phone

Traveler Information

Registration Type

Major Department

Citizenship

Passport Number

Date of Birth

Example: 08/22/1998 (Month/Day/Year)

Passport Expiration Date

Example: 08/22/1998 (Month/Day/Year)

Passport Country of Issuance

Trip Information

Travel Start Date

Travel End Date

Purpose of Travel

Describe Purpose of Travel

Provide name of conference, research project, or group trip.

Mines Faculty Sponsor or Contact

Provide name of faculty member associated with your travel.

Travel Destination(s)

City 1

Country 1

City 2

Country 2

City 3

Country 3

Student Responsibility Statement - for those on Travel Authorizations

Please check each statement to indicate your understanding and willingness to comply with the statement.

I understand that while traveling abroad on a sponsored activity I assume primary responsibility for ensuring my own safety.

I understand I am responsible for knowing and complying with the Covid-19 specific entry requirements for my host country and program provider, including requirements for Covid-19 testing or vaccinations. I plan to meet any requirements for entry, including necessary visas and/or health documentation (such as proof of vaccinations). I will enter the country without the need to quarantine. If I have questions about the host country requirements, I will speak with my host program or faculty sponsor in advance. I understand I am responsible for knowing and complying with the Covid-19 specific requirements needed to return to the United States upon completion of my program. These may include obtaining a negative Covid-19 test at my own expense.

I understand that while abroad, I am expected to abide by the laws of my host country. Additionally, I understand that all CSM policies concerning student conduct, including the Student Code and the policy prohibiting gender-based discrimination, sexual harassment, and sexual violence, also apply to students studying abroad, and that I may be disciplined through CSM conduct code procedures for incidents that occur off campus.

Furthermore, I understand that the legal mandates that protect a person with a disability in the United States do not extend beyond the borders of the United States. I understand that working with the appropriate offices at CSM, I should research the programs and services available at the host institution well in advance of my arrival.

I understand that it is my responsibility to determine if I am required to obtain a student visa to participate in the program and that if I do need a visa that I will apply for it in a timely manner.

I understand that I am expected to purchase CISI insurance.

I understand that I must carry CISI health insurance as required by Mines, that it is my responsibility to download the CISI application on my phone, and to understand how this insurance covers me while I am abroad.

I hereby acknowledge that I have read the most recent U.S. Department of State Travel Warnings for the location(s) listed above, and the Consular Information Sheet on the location(s) listed above. Available at: http://travel.state.gov/travel.

I understand that it is my responsibility to be aware of and to read any revisions or updates to the Travel Warning that are issued between the date when I sign this Release and the date of my return from the Activity. I understand the potential risks traveling to and in the location(s) listed above at this time as explained in the Travel Warning (and any subsequent revisions or updates) and that the security situation may change during my participation in the Activity. I hereby assume, knowingly and voluntarily, each of these risks and all other risks which could arise out of or occur during my travels.

Title IX Information and Protocol While Abroad

By checking the boxes below, you agree that you have read and understand the following information. This information can also be found at: https://www.mines.edu/global/wp-content/uploads/sites/249/2020/08/Travel-Information-from-the-Title-IX-Office.pdf

I have read and understand the Title IX Information and Protocol

Travel Waiver and Release of Liability

This is a legally binding Release, Waiver, Discharge and Covenant Not to Sue (collectively, "Release"), made voluntarily by me, the undersigned Releasor, on my own behalf, and on behalf of my heirs, executors, administrators, legal representatives and assigns (hereinafter collectively, "Releasor," "I" or "me", which terms shall also include Releasor's parents or guardian, if Releasor is under 18 years of age). I fully recognize that there are dangers and risks to which I may be exposed by participating in the activity described on Exhibit A which is attached to and incorporated in this Release (the "Activity"). These risks may include, but are not limited to, personal injury or death, and property damage or loss as a result of traveling to and from and within the United States, one or more foreign countries; foreign political, legal, social and economic conditions; different standards of design, safety and maintenance of buildings, public places and conveyances; local medical, sanitation and weather conditions. I understand that Colorado School of Mines (“CSM”) does not require me to participate in this Activity, but I want to do so despite the possible dangers and risks and the requirement that I sign this Waiver and Release of Liability. I have read the United States Department of State (www.state.gov) consular information about the countries of travel and the Center for Disease Control Travelers’ Health recommendations (http://www.cdc.gov/travel) for any applicable immunization or health risks and incorporated this information into my decision to participate in the Activity. I affirm that I have consulted with a medical doctor with regard to my personal medical needs and that there are no health-related issues which preclude or restrict my participation in the Activity. I affirm that I have adequate medical or health insurance to cover any medical assistance I may require. With informed consent, and in consideration of permission to participate in the program and assistance provided by CSM, I agree to assume all of the risks and responsibilities in any way arising from or associated with the Activity, and I release CSM, the Colorado School of Mines Board of Trustees, the State of Colorado, the State of Colorado Risk Management, and all current and former employees, officials, representatives, agents and volunteers of each of those entities (collectively "Releasees"), from any and all claims, demands, suits, judgments, damages, actions and liabilities of every name and nature whatsoever, occurring after the date of this Release, whether known or unknown, contingent or fixed, at law or in equity (collectively “Liabilities”), that I may suffer at any time arising from or in connection with the Activity, including but not limited to any injury or harm to me, my death, or damage to my property. I further agree to defend, indemnify, and save Releasees harmless from and against any and all Liabilities incurred by any other person as a result of my actions or omissions in connection with the Activity, including but not limited to any injury or harm to another, another’s death or injury to another’s property. I agree that this Release shall be governed for all purposes by Colorado law. Notwithstanding anything herein to the contrary, I understand that all terms and conditions of this Release shall be construed or interpreted as consistent with, and not a as a waiver, express or implied, of any of the immunities, rights, benefits, protection, or other provisions of the “Colorado Governmental Immunity Act”, Section 24-10-101, et seq., CRS, as now or hereafter amended and that any claims for injuries to persons or property arising out of negligence of the State of Colorado, its departments, institutions, agencies, boards, officials and employees is subject to the provisions of Section 24-10-101, et seq., CRS, as now or hereafter amended and the risk management statutes, Section 24-30-1501, et seq., CRS, as now or hereafter amend

Check the box below:

I agree that should any provision of this Release be found to be unenforceable, that all remaining provisions of the Release will remain in force and effect. I have read this entire Release. I fully understand the entire Release and acknowledge that I have had the opportunity to review this Release with an attorney of my choosing if I so desire, and I agree to be legally bound by the Release. THIS IS A RELEASE OF YOUR RIGHTS, READ CAREFULLY AND UNDERSTAND BEFORE SIGNING.

Travel Authorization Application Agreement

By signing below I certify that the information submitted on this given above is true and complete. I agree to release any and all records and transcripts held by Colorado School of Mines or other institution to the Office of International Programs as necessary for my participation in a study abroad program. I understand that as a participant in the study abroad program, I shall be subjected to certain rules and requirements of this university and of cooperative universities, which I agree to fulfill in all respects, subject to immediate dismissal from the program if I do not do so. I agree to assume financial responsibility for the program fees and for my own welfare while overseas. I understand that the Office of International Programs reserves the right to cancel, alter or amend any part of any program or to increase charges should circumstances make these actions advisable or necessary.

Signature

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