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.

* Indicates a required field

TRAVELER INFORMATION

Full Name*
Department/Program*
Email*
Phone Number*
Status*	Select OneSOM StudentGSBS StudentGSN StudentResidentPost-Doc FellowFacultyStaffOther
Citizenship*
Who is your employer*	Select OneUMass Medical SchoolDual (UMMS & UMMHC)

LOGISTICAL INFORMATION

Destination(s)*
Accommodations*
Departure Date*	[None]
Return Date*	[None]
Global Phone Number*
Travel Companion(s)

PROGRAM INFORMATION

Program/Organization Name*
Program Contact (Name, Title, Email, Phone, Website)*
Purpose and Goals of Travel (select all that applies)	International elective/educational experiencePatient care/medical missionResearchTeachBuild international collaboration/partnershipAttend conference/symposiumPresent at conference/symposiumTechnical assistance/consultingOther
If other, please specify
Will you be doing any clinical work?	Please selectYesNo
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.)*	Please selectYesNo

EMERGENCY CONTACT INFORMATION

In-country emergency contact:
Name*
Relation*
Email*
Phone*
US emergency contact:
Name*
Relation*
Email*
Phone*
In-country emergency plan (e.g. What is your evacuation plan? Can you access medical care? What is your crisis communication plan? Who are your on-site contacts?)*	Type above to enter Emergency Plan (Required)

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.

1. I agree to the above
2. I do not agree to the above

Students and other trainees are required to complete the following. Although highly recommended, the following actions are not required of faculty/staff.

Consult US State Department Travel Warnings/Alerts and CDC Travel Health Notices for travel advice and entry/exit requirements. Obtain travel approval from your program director and OGH if traveling to a country or region with a Warning or Alert.

Obtain current travel health information and necessary vaccines & medications (See Student Health Services).

Register travel with the US State Department through the Smarter Traveler Enrollment Program.

Obtain international travel insurance. Upon completion of this travel registration form, you will be prompted to download and print the AIG travel insurance packet.