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EXCHANGE FOR SOCIAL ENTREPRENEURS & LEADERS (XSEL)

1. VI A Program Rul es

It is not possible to predict every situation that may arise during your visit to the United States. There are also risks you
must understand and accept of program activities, such as hiking, horseback riding, kayaking, and other free-time
activities on or off Stanford campus. In order to participate in the program, you must be fully responsible for your safety,
and release VIA from any and all liability for any damage or injury.

We expect all participants to be proactive and responsible during the program for their personal health and safety, and to
exercise appropriate caution and judgment in their conduct and behavior. In order to protect your personal health and
safety, and to minimize any risks or dangers you may encounter while on the program, it is necessary to abide by the
rules and regulations set by Stanford University, and the laws of the State of California and the United States of America.

For your participation in VIA, you must also agree to comply with the following rules:

(i) You must arrange and purchase personal health insurance before your departure to the United States. In
addition, should your physician have any reason to object to your participation in the program, you must
inform VIA staff immediately. You must also inform VIA staff of any medical treatments or prescription
drugs you are receiving, or any medical conditions, that may affect your participation and/or health during
the program.

(ii) The following activities and actions are prohibited during the program:

a. Drinking alcohol, regardless of age, and using illegal drugs
b. Carrying/using any weapons
c. Sexual harassment and lewd conduct
d. Renting or driving a car
e. Overnight stays away from the Stanford dormitory (stays with family/relatives near Stanford University
may be allowed with prior approval from the program director)

Should you violate any of these rules, VIA may send you back to Asia at your own expense.

(iii) If you become ill or are unable to make medical decisions, VIA will take all actions necessary for the
provision of medical services including, if needed, hospitalization and arrangements for transportation
home.

(iv) VIA cannot take responsibility for periods in which you leave the program (in or out of the U.S.) for
independent travel or visits before, during, or after the program. You must take full responsibility for your
acts and behavior.


2. Use of Personal I nformati on and I mages

(i) VIA will use/disclose your personal information for:

a. VIAs database management
b. VIA staff, including student coordinators
c. VIA Japan or Taiwan Alumni Committees (JAC or TAC)

VIA will not disclose your personal information to any outside entities without your approval.

(ii) Photographs and/or videos of the participants taken during the program may be used for promotional
activities, including but not limited to newsletters, annual reports, website, blog posts, posters, etc. If you
do not want your image used, please inform VIA staff before the start of the program.


EXCHANGE FOR SOCIAL ENTREPRENEURS & LEADERS (XSEL)
Participant Agreement Form

Program Dates: August 3 23, 2014


I, (participants name) ____________________________________, have read the VIA program rules and statement
regarding the use of personal information and images, I understand the contents, and I agree to the conditions stated by
VIA. I understand that the agreement shall become effective upon departure to the U.S. Any disputes will be resolved by
arbitration under the laws of California and in California.

I agree to be fully responsible for my safety and I release VIA from any and all liability for damage and injury from
unpredictable situations that may arise during my visit to the U.S. I agree to exercise good judgment and act in an
appropriate manner during the program. I understand that failure to do so may result in my expulsion from the program by
VIA, and being sent home to Asia at my own expense.


Participants Name:



Signature Date



PARENT OR GUARDIAN INFORMATION (Please write in English.)


Name: Relationship:


Address:


Telephone: Fax (if available):


E-mail (if available):



Signature Date



HEALTH INFORMATION (Please write in English.)


Please describe any medical conditions you have:



Do you have any special dietary conditions?