Intercultural Immersion Application
Wesley Theological Seminary
Practice in Ministry and Mission Program 

Complete the form and submit to the PM&M Office.  For January immersions, submit no later than November 16th (or nearest school day after the date); for Summer immersions, submit no later than April 1st (or nearest school day after the date).  *Please note that all trips are subject to cancellation.

Don’t forget to register for MM-350 PM&M: Intercultural Immersion  

Name:

Address:

Email:  						Cell phone: 

Degree Program:								

Current number of Credit Hours:		Anticipated Graduation Date:

Proposed Immersion:

Starting and ending dates of proposed immersion experience:

Why is this intercultural experience appropriate for you?

__________________________________________________________________________

What are your preliminary learning goals for this experience?

__________________________________________________________________________

If you are currently in a PMM placement, how have your Learning Partners and ministry setting been involved in planning for this experience?

__________________________________________________________________________

__________________________________________________________________________

If you are currently in a PMM placement, how do you imagine you might share this experience with your ministry setting?  If you are not in PMM, how do you imagine you might share this experience with your home church or ministry setting of choice? 

__________________________________________________________________________

__________________________________________________________________________

 

SIGNATURE PAGE 

INSTRUCTIONS:  

1.	All students are required to sign this form. 

2.	If you are not currently in a PMM Colloquy, you only need the signature of your Wesley Seminary Academic Advisor; you are not required to have the signature of the PMM Learning Partnership.  

3.	If you are in a PMM Colloquy, you only need the signature of both learning partners (clergy and lay partners); you are not required to have the signature of your academic advisor.

4.	The PMM Office will sign and approve the application only after a completed application has been submitted.

Student Signature

Student:						Campus Box #:		Date:

Academic Advisor Signature (if not in PMM Placement)

Academic Advisor:									Date:

Learning Partner Signatures (if already in PMM Placement)

Clergy Partner:									Date:

Lay Learning Partner:								Date:

Practice in Ministry and Mission Signature (to be signed upon receipt of completed application)

											Date:
Josie Hoover, Assistant Director

Intercultural Immersion Waiver Forms

INSTRUCTIONS:

On the following pages, there are two versions of the waiver forms of which one is to be submitted with your application.  Complete the appropriate waiver form, depending on whether or not you are participating in a Domestic Immersion or International Immersion.  Please be sure to attach the appropriate waiver form to your application.

Wesley Theological Seminary
Domestic Immersion Waiver

This form is intended to be signed by all students, guests, and other non-employees participating in Intercultural Immersion trips.

_________________________________________
(Name of Intercultural Immersion)

RELEASED AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMINITY AGREEMENT

I, ____________________________________, hereby acknowledge that I have voluntarily elected to participate in the following immersion trip ______________________________________to be held in and around (location) ___________________________________, from ______________ to ___________.  In consideration for being permitted by Wesley Theological Seminary to participate in this Intercultural Immersion, I hereby acknowledge and agree to the following:

ELECTIVE PARTICIPATION:  I acknowledge that my participation is elective and voluntary in accordance with the seminary’s course requirement for Intercultural Immersions.

RULES AND REQUIREMENTS:  I agree to conduct myself in accordance with seminary policies and procedures, including the Covenant of Professional Ethics and Behavior and the Sexual Harassment Policy.  I further agree to abide by all the rules and requirements of the Immersion.  I acknowledge that Wesley Theological Seminary has the right to terminate my participation in the Immersion if it is determined that my conduct is detrimental to the best interest of the group, my conduct violates any rule of the Immersion, or for any other reason in the seminary’s discretion.

INFORMED CONSENT:  I have been informed of and I understand the various aspects of the Immersion, including the dangers, hazards, and risks inherent in the Immersion, including but not limited to transportation to and from Wesley Theological Seminary via private vehicle, common carrier participation in the Immersion, overnight accommodations, weather conditions, conditions of equipment, facility conditions, negligent first aid operations or procedures, and in any independent research or activities I undertake as an adjunct to the Immersion.  I understand that as a participant in the Immersion I could sustain serious personal injuries, illness, property damage, or even death as a consequence of not only the Seminary’s actions or inactions, but also the actions, inactions, negligence or fault of others.  I further understand and agree that any injury, illness, property damage, disability or death that I may sustain by any means is my sole responsibility except for those occurrences due to the Seminary’s negligence or intentional acts. 

RELEASE AND WAIVER OF LIABILITY:  I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents and assigns, HEREBY RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE Wesley Theological Seminary, it’s governing board of directors, officers, employees, agents, volunteers, and any students (hereinafter referred to as “Releasees”) for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys’ fees), arising from any injury, property damage or death that I may suffer as a result of my participation in the Immersion, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES, UNLESS THE INJURY DAMAGE OR DEATH IS CAUSED BY THE RELEASEES’ NEGLIGENCE OR INTENTIONAL ACTS, AND REGARDLESS OF WHETHER THE INJURY DAMAGE OR DEATH OCCURS WHILE IN, ON, UPON, OR IN TRANSIT TO OR FROM THE PREMISES WHERE THE IMMERSION OR ANY ADJUNCT TO THE IMMERSION, OCCURS OR IS BEING CONDUCTED.  I further agree that the Releasees are not in any way responsible for any injury or damage that I sustain as a result of my own negligent acts.

ASSUMPTION OF RISK:  I understand that there are potential dangers incidental to my participation in the Immersion, some of which may be dangerous and which may expose me to the risk of personal injuries, property damage, or even death.  I understand that there are potential risks as a consequence of, but not limited to:  participation in this Immersion, travel to and from _________________________ via private vehicles, common carriers, and/or Seminary owned vehicles, weather conditions, overnight accommodations, facility conditions, equipment conditions, first aid operations or procedures of Releasees, and other risks that are unknown at this time.  I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE ACTS OF THE RELEASEES, UNLESS THEY ARISE FROM THE RELEASEES’ INTENTIONAL OR NEGLIGENT ACTS, and assume full responsibility for my participation in the Program.

INDEMNITY:  I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, agree to hold harmless, defend and indemnify the Releasee from any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys’ fees), arising from any injury, property damage or death that I may suffer as a result of my participation in the Immersion, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES OR OTHERWISE, UNLESS THE INJURY DAMAGE OR DEATH IS CAUSED BY THE RELEASEES’ NEGLIGENCE OR INTENTIONAL ACTS.

CERTIFICATION OF FITNESS TO PARTICIPATE:  I attest that I am physically and mentally fit to participate in the Immersion and that I do not have any medical record of history that could be aggravated by my participation in this particular Immersion.

MEDICAL CONSENT:  I understand and agree that Releasees may not have medical personnel available at the location of the Immersion.  In the event of any medical emergency, I  (initial) do ____ do not ____ authorize and consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment, and hospital care that the Seminary personnel deem necessary for my safety and protection.  I understand and agree that Releasees assume no responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment. I understand and agree that I am responsible for my individual medical insurance.  

CHOICE OF LAW:  I hereby agree that this Agreement shall be construed in accordance with the laws of the District of Columbia.

SEVERABILITY:  If any term or provision of this Agreement shall be held illegal, unenforceable, or in conflict with any law governing this Agreement the validity of the remaining portions shall not be affected thereby.

(INTENTIONALLY LEFT BLANK)

I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS.  I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES.  I UNDERSTAND I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.  BY MY SIGNATURE I REPRESENT THAT I AM AT LEAST EIGHTEEN YEARS OF AGE.

___________________________________
Signature of Participant

___________________________________
Date

Adopted 6/2006

Revised 7/2012

Wesley Theological Seminary
International Immersion Waiver

This form is intended to be signed by all students, guests, and other non-employees participating in Intercultural Immersion trips.

_____________________________________
(Name of Intercultural Immersion)

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

I, ____________________________________, hereby acknowledge that I have voluntarily elected to participate in the following immersion trip ______________________________________to be held in and around (location) ___________________________________, from ______________ to ___________.  In consideration for being permitted by Wesley Theological Seminary to participate in this Intercultural Immersion, I hereby acknowledge and agree to the following:

ELECTIVE PARTICIPATION:  I acknowledge that my participation is elective and voluntary in accordance with the Seminary’s course requirement for Intercultural Immersions.

RULES AND REQUIREMENTS:  I agree to conduct myself in accordance with seminary policies and procedures, including the Covenant of Professional Ethics and Behavior, and the Sexual Harassment Policy.  I further agree to abide by all the rules and requirements of the Immersion.  I acknowledge that Wesley Theological Seminary has the right to terminate my participation in the Immersion if it is determined that my conduct is detrimental to the best interests of the group, my conduct violates any rule of the Immersion, or for any other reason in the Seminary’s discretion.

I understand that in the event my participation in the Program is terminated for violating any rule of the Program, I will be solely responsible for the cost of return travel.  I further understand and agree that the Seminary is not responsible for any injury or damage that I sustain if I travel independently or am otherwise separated or absent from Seminary sponsored activities.  I acknowledge that I am solely responsible for any legal problems I encounter with any foreign nationals or government and the Seminary is not responsible for providing any assistance under those circumstances.

INFORMED CONSENT:  I have been informed of and I understand the various aspects of the Program, including but not limited to the fact that the Program will be held in and around ____________________________ (location).  I understand that travel outside the United States is considered dangerous and I accept the risks of such travel.  I have received and reviewed the travel itinerary from the Immersion and understand the risks involved in traveling to, within and from ____________________________, including but not limited to foreign political, legal, social, and economic conditions, language barriers, safety hazards, crime, disease, consumption of food, civil unrest or hostilities, terrorism, war, natural disasters and weather conditions, and negligent first aid operations or medical treatment.  I further understand that serious injuries could occur during my participation in the Program and that as a Participant I could sustain personal injuries, property damage, or even death as a consequence of participating in this Immersion, local transportation to and from various activities, international travel to and from ________________________________ (Immersion location).

I understand that serious injuries could occur during participation in this Program and that as a Participant, I could sustain serious personal injuries, illness, property damage, or even death as a consequence of not only the Seminary’s actions or inactions, but the actions, inactions, negligence or fault of others and that there may be other risks not known to me or not reasonably foreseeable at this time.  I further understand and agree that any injury, illness, property damage, disability, or death that I may sustain by any means is my sole responsibility except for those occurrences due to the Seminary’s negligence or intentional acts.  

RELEASE AND WAIVER OF LIABILITY:  I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, HEREBY RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE Wesley Theological Seminary, its governing board, directors, officers, employees, agents, volunteers and any students (hereinafter referred to as “Releasees”) for any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys’ fees), arising from any injury, property damage or death that I may suffer as a result of my participation in the Immersion, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES’ NEGLIGENCE OR INTENTIONAL ACTS, AND REGARDLESS OF WHETHER THE INJURY DAMAGE OR DEATH OCCURS WHILE IN, ON, UPON, OR IN TRANSIT TO OR FROM THE PREMISES WHERE THE IMMERSION OR ANY ADJUNCT TO THE IMMERSION, OCCURS OR IS BEING CONDUCTED.  I further agree that the Releasees are not in any way responsible for any injury or damage that I sustain as a result of my own negligent acts.

ASSUMPTION OF RISK:  I understand that there are potential dangers incidental to my participation in the Program, some of which may be dangerous and which may expose me to the risk of personal injuries, property damage, or even death.  I understand that these potential risks include, but are not limited to:  travel to and from _________________________________, local transportation within the Immersion location, including but not limited to foreign political, legal, social, and economic conditions, language barriers, safety hazards, crime, disease, consumption of food, civil unrest or hostilities, terrorism, war, natural disasters and weather conditions, negligent first aid operations or medical treatment, and other risks that are unknown at this time.  I KNOWINGLY AND VOUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE ACTS OF THE RELEASEES, UNLESS THEY ARISE FROM THE RELEASEES’ INTENTIONAL OR NEGLIGENT ACTS, and assume full responsibility for my participation in the Program.

INDEMNITY:  I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, agree to hold harmless, defend and indemnify the Releasees from any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys’ fees), arising from any injury, property damage or death that I may suffer as a result of my participation in the Immersion, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE RELEASEES OR OTHERWISE, UNLESS THE INJURY DAMAGE OR DEATH IS CAUSED BY THE RELEASEES’ NEGLIGENCE OR INTENTIONAL ACTS.

PESONAL BELONGINGS:  I understand and acknowledge that the Seminary is not responsible for the loss of any personal belongings or property that I sustain during my participation in the Immersion including but not limited to the loss of credit cards, cash, luggage, and other items.

MEDICAL CONSENT:  I understand and agree that Releasees do not have medical personnel available at the location of the Program.  In the event of any medical emergency, I (initial) do ____ do not _____ authorize and consent to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment, and hospital care that the Seminary personnel deem necessary for my safety and protection.  I understand and agree that Releasees assume no responsibility for any injury or damage which might arise out of or in connection with such authorized emergency medical treatment.  

CHOICE OF LAW:  I hereby agree that this Agreement shall be construed in accordance with the laws of the District of Columbia.

SEVERABILITY:  If any term or provision of this Agreement shall be held illegal, unenforceable, or in conflict with any law governing this Agreement the validity of the remaining portions shall not be affected thereby.

I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS.  I AM AWARE THAT THIS AGREEMENT INCLUDES A RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE REALEASEES.  I UNDERSTAND I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS AGREEMENT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.  

BY MY SIGNATURE I REPRESENT THAT I AM AT LEAST EIGHTEEN YEARS OF AGE OR, IF NOT, THAT I HAVE SECURED BELOW THE SIGNATURE OF MY PARENT OR GUARDIAN AS WELL AS MY OWN.

______________________________
Signature of Participant

______________________________
Date

Adopted 6/2006

Revised 7/2012

Medical Information for Immersion Trips 

Student General Information: (please print)

Name:								DOB:

Address:

Home Phone:							Cell Phone: 

Primary Care Physician:					Phone:

Emergency Contact Information

Name:								Relation:

Address:

Home Phone:							Work Phone:

Cell Phone: 							Email: 

Medical Information 

Are you presently being treated for an injury or sickness or taking any form of medication for any reason?  ___ Yes  ___ No.  If yes, please explain and list medications:

Are you allergic to any type of medication?  ___ Yes   ___ No.  If yes, please list:

Please list all allergies:

Do you require a special diet?  ___ Yes   ___  No.  If yes, please explain:

Do you or (have you ever had) any of the following?  Circle and explain below:

Seizure Disorders			Asthma 			Heart Murmur

Hay Fever				Kidney Disease		Diabetes

Do you have any allergies other than medical?  ___ Yes ___ No.  If yes, please explain:

Do you have any physical handicaps or illnesses which would prevent you from participating in normal rigorous activities?  ___  Yes   ___ No.  If yes, please explain:

Medical Treatment Authorization

I understand this form will be used to judge medical attention given to me in the event of an emergency and I authorize the calling of a doctor for the providing of necessary medical services.

I agree to notify the Wesley Theological Seminary representative in the event of any health changes, which would restrict my participation in any normal activities before and during this trip.

Print Name:

Signature:

Name of Health Insurance Company:

Insurance Company contact number:

Policy Number:

Note:  This information is intended exclusively for the use of the immersion trip leader and will be shared only with those who might need to administer medical care.  Your immersion leader has been instructed to destroy this information at the conclusion of your immersion experience.   

Intercultural Immersion Certification 

NOTE:  RETAIN THIS CERTIFICATE AND TAKE IT WITH YOU FOR A SIGNATURE AT THE CONCLUSION OF YOUR IMMERSION

Name:									

Name of Intercultural Immersion attended:

Dates of Participation:  

This form is submitted to certify completion of the above immersion experience and the Debriefing Seminar.

SIGNATURES

Student								Date

Immersion Sponsor or Representative				Date

Debriefing Seminar Faculty						Date

COMMENTS ABOUT STUDENTS’ PARTICIPATION (OPTIONAL):
To be completed by Immersion Leader as needed: 

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Please submit this form to the PM&M Office no later than the completion of the Debriefing Seminar that follows the completion of your Immersion experience.

Received by:								Date