Global Leadership & Engagement Program

1. VIA Program Rules
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. 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.
b.
c.
d.
e.

Drinking alcohol, regardless of age, and using illegal drugs
Carrying/using any weapons
Sexual harassment and lewd conduct
Renting or driving a car
Overnight stays away from the program (stays with family/relatives near Stanford University or
San Francisco 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 Information and Images
(i)

VIA will use/disclose your personal information for:
a. VIA’s database management
b. VIA staff, including Stanford coordinators
c. VIA Beijing, Japan or Taiwan Alumni Committees (BAC, 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.

Global Leadership & Engagement Program
Participant Agreement Form
Program Dates: February 8 - 18, 2017
I, (participant’s 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.

Sara Kadono

Participant’s Name:

Sara Kadono

1/3/2016

Signature*

Date

* Parent/Guardian signature not necessary if participant if over 25 years old.

PARENT OR GUARDIAN INFORMATION (Please write in English.)
Name:
Address:

Kenji Kadono

Relationship:

Father

105 1-4-2 Seishin-cho, Edogawa-ku, Tokyo, 134-0087 JAPAN

Telephone:
E-mail (if available):

+81 338778788

Fax (if available):

+81 338778788

mokadonoo@gmail.com

Kenji Kadono
Signature

1/3/2016
Date

HEALTH INFORMATION (Please write in English.)
Please describe any medical conditions you have:

Do you have any special dietary conditions?

None

Fish egg allergy