CSCE
Hello,
We are excited that you are interested in pursuing an international placement. Many students find
these placements to be an enriching experience, both on a professional and personal level.
The following Checklist is intended to assist you in organizing a learning experience in a country
outside of Canada.
Please ensure that you read through this document carefully and complete Sections 1 – 5. You are
expected to complete this form independently and be resourceful in your problem solving. Please
make an appointment to speak with your Academic Coordinator of Clinical Education when you
have completed these forms.
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Checklist for Students Requesting an International Placement
Please complete the following 5 pages (Sections 1 – 4) and submit a copy to your Academic Coordinator of
Clinical Education along with the required documents.
1. To Be Eligible for an International Placement:
Yes, I have completed or met the following requirements;
I am a senior level student in good standing, and specifically I have a clean history within the Faculty of
Rehabilitation Medicine in both academic and clinical education courses (i.e., no course failures or borderline
performance, no professional behaviour issues or concerns).
I have read the Education Abroad Handbook
http://www.international.ualberta.ca/students/goabroad/whileabroad/
___________________________(date completed)
I have submitted a written proposal to my Clinical Education Coordinator outlining my reasons for requesting
an international placement, the projected outcomes of this placement and the impact on my learning.
___________________________(date completed)
I have completed the attached: Request for International Placement(s) forms and have ensured that I will have
sufficient funds to cover all costs for the proposed international placement.
___________________________(date completed)
I have checked the website of the; Canadian Department of Foreign Affairs – Travel Assistance, Travel Update
(http://www.dfait-maeci.gc.ca/menu-en.asp), and I accept that if there is a travel advisory in place to the
country I am requesting, that the placement will not be permitted.
___________________________(date completed and status)
I have completed the medical requirements / immunizations for travel to my requested international site.
___________________________(date completed and status)
I will ensure (through the ACCE) that a contract is in place with my international site before I confirm/pay for a
flight.
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2. Prior to Leaving Canada You are Required to Have the Following Items:
Yes, I have the following;
    Proof of Citizenship and Immigration Documentation
                  -passport and appropriate Visa
                  -ensure that “hands on” interaction with clients will be permitted
Proof of Personal (extended) medical and health insurance
             -including evacuation coverage
Detailed Emergency Plan (including contacts and repatriation)
             - Register at the International Centre and bring this information with you when you go
          http://www.international.ualberta.ca/students/goabroad/whileabroad/
             - (register with Canadian Embassy when you arrive in the other country)
Communication Plan for University of Alberta Academic Coordinator of Clinical Education (i.e., I know how I
will contact you and when).
I have signed and submitted an original copy of the U of A Release of Liability, Waiver of Claims, Assumption
of Risks and Indemnity Agreement.
I have a back up plan. I know what I will do if my placement is cancelled. I know how this will affect my
graduation an my employment opportunities.
3. Optional, However Very Strongly Recommended
Travel insurance (baggage, cancellation, delays etc.)
If you are traveling to a developing country, attendance at an International Centre “Pre-Departure Briefing”.
Typically these are held in the fall & spring. http://www.international.ualberta.ca/
Presentation to other students or write an article for the student newspaper or professional newsletter.
Other_________________________________________________________
Other_________________________________________________________
Other_________________________________________________________
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                        THE UNIVERSITY OF ALBERTA
                           [Department/Faculty Name]
RELEASE OF LIABILITY, WAIVER OF CLAIMS, ASSUMPTION OF RISKS AND INDEMNITY
                                AGREEMENT
WARNING: PLEASE READ CAREFULLY! By signing this document you indicate that you understand the
risks associated with this activity, that you are aware that by participating in the activity you are being exposed to
the risks identified below, and that you accept important legal obligations and waive certain legal rights, including
the right to sue.
NAME OF PARTICIPANT: ______________________________________________
________________
ADDRESS OF PARTICIPANT:
______________________________________________________________________________
BIRTH DATE: _____________________________________
________________________________
EMERGENCY CONTACT: ______________________________________ TELEPHONE NO: _________________________
REASON FOR THE TRIP
TELEPHONE NO:
STUDENT ID #
DATES: From:
LOCATION
To:
(City/Town, Province/State, Country) (Referred to as “this Trip” throughout this document):
DISCLAIMER CLAUSE
The Governors of the University of Alberta, [Department/Faculty Name], their officers, directors, employees,
volunteers, members and representatives (hereafter referred to as “The University”) are not responsible for any
injury, death, loss or damage of any nature whatsoever sustained by any person while participating to this Trip,
including detention, imprisonment, illness, death or dismemberment or loss or damage to personal property arising
out of any cause whatsoever, including the negligence of the University. The University accepts no responsibility
and assumes no liability with respect to any academic, vocational, medical, or financial advice received by me in
relation to this Trip
ASSUMPTION OF RISKS AND RESPONSIBILITIES
The participant acknowledges that this trip involves inherent risks, dangers, hazards and liabilities to the participant.
The participant fully understands and assumes the following risks that may result in personal injury, death, property
damage, legal expenses and other losses arise from, but are not limited to:
    1. Travel to and from Canada, various locations the participant may include as part of this Trip, travel by bus,
         public or private motor vehicle, train, aircraft and personal activities that the participant involve in.
    2. Street crime, armed robberies, carjacking, rape, credit card fraud, and diseases not common in Canada.
    3. The medical facilities of this Trip may well be of a lower standard than expected in Canada and are
         limited.
    4. The Location of this Trip may have a high incidence of many diseases not common in Canada.
    5. The Location of this Trip may have hazards resulting from military and/or terrorist activity, previous or
         present, such as unexploded land mines and munitions.
    6. It is the participant’s sole responsibility to obtain a valid Passport or other satisfactory proof of residency as
         accepted for entrance into and exit from above noted location.
    7. There are many aspects of the travel are outside of the direct control of the University. It is always possible
         that this Trip might not be completed or individual activities may be curtailed or cancelled, due to weather,
Placements.International.Application.BB.06

    illness, political disturbances, terrorism, motor vehicle accidents, transportation problems and/or accidents,
    tribal violence, failure to perform on part of the travel agents, airlines or tour companies, problems relating
    to customs, immigration or visa requirements.
8. The participant should maintain a high level of personal security awareness, monitor local news reports
    closely, and avoid large crowds or gatherings.
9. The participant should particularly cautious when leaving banks and automated teller machines.
10. It is the participant’s responsibility to learn as much as possible about the risks of the venture, to weigh
    those risks against the advantages, and to decide whether or not to participate.
Initials: ______________
MEDICAL/HEALTH & TRAVEL INSURANCE
1. I AM SOLELY RESPONSIBLE to select and purchase adequate medical/health insurance including out of
   province medical coverage. In the event of a medical/health problem, the University of Alberta accepts no
   responsibility for any costs associated with a medical/health problem nor will it pay for any medical/health
   expenses, which may be incurred by me.
2.
I AM SOLELY RESPONSIBLE to select and purchase adequate travel insurance. The travel insurance should
provide coverage against theft, personal accident, personal liability, repatriation and cancellation of tickets. The
University of Alberta accepts no responsibility for any costs associated with these types of problems nor will it
pay for any expenses that may be incurred by me relating to these areas.
I freely accept and assume all responsibility to provide myself with medical/health and travel insurance coverage.
          Initials: ______________
RELEASE OF LIABILITY, WAIVER OF CLAIMS AND INDEMNITY AGREEMENT
In consideration of The University allowing me to participate in this Trip, I agree as follows:
     1. TO RELEASE THE UNIVERSITY from any and all liability from set backs or course incompletion
         including any effect that may have on my dissertation that I may suffer as a result of my participation in
         this Trip, and in the Location of my choice;
     2. TO HOLD HARMLESS AND INDEMNIFY THE UNIVERSITY and its respective directors, officers,
         agents, contractors, employees, volunteers, representatives from any and all claims, demands, actions and
         costs which might arise out of my participation in this Trip and all related activities:
              • for any damage to the property of, or personal injury to, any third party, resulting from my
                  personal time and non-academic travels during this Trip;
              • in connection with the service of any train, vessel, carriage, aircraft, bus, boat, motor vehicle or
                  other conveyance which may be used in my participation in this Trip. Neither will the University
                  of Alberta assume any liability for any injury loss, accident or delay which may be occasioned by
                  reason of any defect in any vehicle or through the act, error, neglect, negligence or default of any
                  company or person engaged in conveying myself during participation in this Trip;
              • for any cancellation, injury, loss accident or delay occasioned by the proprietor, employee, or
                  service of any hotel, hostel or other type of accommodation used by me during participation in
                  this Trip;
              • for any injury, illness or death that I may sustain, which are related to or caused by any alcohol
                  consumption while traveling and participating in this Trip.
FREE TIME: I will assume all responsibility for activities that I engage in during any and all times of this Trip
when I am not involved in formal course work. Due to the nature of the location of this Trip, I will use the buddy
system whenever possible and where not possible, I will advise those I am working with or living with as to my
course work, plans or activities and the locations of these. I also recognize that I am a representative of the
University of Alberta while on this Trip whether I am conducting course work or on free time and my conduct will
reflect this representation at all times.
This agreement shall be effective and binding upon my heirs, next of kin, executors, administrators, and
representatives in the event of my death or incapacity. In entering into this Agreement, I am not relying upon any
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oral or written representations or statements made by the University of Alberta other than what is set forth in this
agreement.
ALBERTA Freedom of Information and Protection of Privacy Act (FOIPP): By signing below, I consent to
having the information in this document collected by the University. The personal information requested on this
form is collected under the authority of the Universities Act and Section 33 (c) of the FOIPP Act to determine
participation in this Trip. Certain personal information may be made available to federal and provincial
government departments and agencies under appropriate legislative authority. Personal information is protected
under the Alberta FOIPP Act.
I ACKNOWLEDGE that I have read and understood this agreement; that I appreciate and accept the risks
associated with this Trip; that I am waiving legal rights which I or my heirs, next of kin, executors, administrators
and legal representatives may have against the University of Alberta; and that I have executed this agreement
voluntarily.
SIGNED THIS
________
day of ___________________,
20____ at Edmonton, Alberta.
_________________________________________
       ____________________________________
____________________
              WITNESS SIGNATURE
SIGNATURE OF PARTICIPANT
_________________________________________
PRINTED NAME OF PARTICIPANT
       ____________________________________
_____________________
       PRINTED NAME OF WITNESS
___________________________________________
______________
WITNESS ADDRESS & PHONE NUMBER
This agreement must be completed in full, signed, dated, and witnessed before the participant is allowed to
participate in the trip.
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REQUEST FOR INTERNATIONAL CLINICAL PLACEMENT
GENERAL INFORMATION
Date:
Student Name:
Current Address:
Phone# (Edmonton):
E-mail:
Phone # Other:
PLACEMENT PARTICULARS
Preferred Placement Dates:
Preferred Area of Practice:
first choice:
second choice:
third choice:
Year:
BUDGET
ITEM
Travel Expenses
- e.g. Air Fare
Room and Board
Transportation
Medical Insurance
Visa Fees
Supervisory Fees
Licensing Fees
Entertainment
Miscellaneous
Total
Site #1
Site # 2
Site # 3
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FACILITIES
Using research tools, such as the Internet, please fill in the information requested on three prioritized facilities you
would like to be place at. The information must be completed in order for your ACCE to contact the appropriate site
person in order to finalize a contract.
#1 - Name of Facility:
Address of Facility:
Contact Name:
Role of your contact (i.e. CI, Superintendent, Manager):
E-mail, Phone, Fax:
How did you find this facility?
Please provide details or copies of any documentation or communications.
#2 - Name of Facility:
Address of Facility:
Contact Name:
Role of your contact (i.e. CI, Superintendent, Manager):
E-mail, Phone, Fax:
How did you find this facility?
Please provide details or copies of any documentation or communications
#3 - Name of Facility:
Address of Facility:
Contact Name:
Role of your contact (i.e. CI, Superintendent, Manager):
E-mail, Phone, Fax:
How did you find this facility?
Please provide details or copies of any documentation or communications
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