Safety Forms

Exception Petition Agreement for Individual Travelers - Standalone


Voluntary Participation and University’s Right to Withdraw Approval:

No Northeastern University student, faculty, or staff member is required to travel to a high-risk location. Any participation in travel to a high-risk location is strictly voluntary, and the traveler assumes full responsibility for all risks associated with this travel. The traveler understands the university may be limited in its ability to provide assistance and resources in the event of a crisis The university retains the right to withdraw approval and/or require the traveler to leave the high-risk location, at any time.

Please initial here to acknowledge the above statement:  

TRAVEL WAIVER AGREEMENT: Please review the information below and sign the following agreement:

Traveler Name:  
Current Cellphone Phone:  

Program Information

Program Start Date:
Program End Date:
Date of Arrival in Country:
Host Institution Name or Co-op Employer Name:  
List Destinations (max 3):  

In connection with my travel to the Program and Travel Locations referenced above, and any other related travel, including, without limitation, personal travel for the purpose of education, personal business, social service or other experience:

  1. I acknowledge that I am voluntarily participating in the travel described above and I know that I am not required to travel to my Travel Location(s).
  2. I have carefully identified, reviewed and considered the risks of traveling the my Travel Location (s), including reading the most recent relevant U.S. Department of State (“DoS”) Travel Warning(s) (http://travel.state.gov), any applicable U.S. Centers for Disease Control and Prevention Travel Notice Level Three: Avoid Nonessential Travel (a “CDC Level 3”) ((http://wwwnc.cdc.gov/), the most recent relevant International Security Alerts and Security Reports from the univeristy’s international response provider (found using the “My Travel Plans” link on the myNortheastern Portal).,and the latest travel advisories from the World Health Organization (http://www.who.int/ith/en/).
  3. I acknowledge that my participation in this travel may expose me to significant risks, including but not limited to terrorism, war, disease, serious bodily injury or death, property damage, and other risks that may not be foreseeable. I acknowledge that the U.S. State Department has issued a Travel Warning and/or the U.S. Centers for Disease Control and Prevention has issued a Travel Notice Level Three: Avoid Non-essential Travel for the above Travel Location(s) and/or the university’s international response provider rates the risks of travel to the Travel Location as HIGH or SEVERE and/or a travel advisory has been issued by the World Health Organization. I understand that Northeastern University (“Northeastern”) is not responsible for my safety, the University may be limited in its ability to provide assistance and resources in the event of a crisis and I assume full responsibility for all risks associated with my travel.
  4. I understand it is my responsibility to review the health risks associated with my Travel Location(s) through the CDC Travelers Health resource, available at https://wwwnc.cdc.gov/, and to discuss required or recommended vaccinations with a travel health professional, if applicable.
  5. I freely accept all the risks associated with this travel. I expressly agree that I am not an employee of Northeastern, and have no employee rights or benefits including, without limitation, any workers’ compensation benefits. I acknowledge that it is my responsibility to ensure that I have adequate medical, personal health and accident insurance coverage, as well as any insurance protection for my personal possessions.
  6. I acknowledge that it is my responsibility to abide by all applicable Northeastern policies, the laws of the host country and any country to which I am traveling, and the rules/regulations of the host company/organization, and to comply with those and all travel requirements set forth by Northeastern University, GSSAC and/or the trip leader/sponsor, program director or coordinator on site.  I further acknowledge that I am required to adhere to all applicable Northeastern University rules and regulations, including but not limited to those in the applicable Northeastern University student handbook.  I understand that if I fail to comply with any such requirements I may be dismissed from the program.  I understand that if I am dismissed from the program for a violation of any applicable rules, including this Agreement, I may not receive academic credit or a refund of tuition or any other fees or expenses paid for the program and that I may incur additional personal and/or travel expenses, and may face additional sanctions upon return to Northeastern up to and including expulsion from the university, and withdrawal of funding or financial aid for expenses in connection with the program.
  7. I affirm that I have submitted a complete and accurate petition for my proposed travel to Northeastern University’s Global Safety and Security Assessment Committee (GSSAC) and that it has been approved by the Provost, or I am participating in a program that has permission from the Provost. I acknowledge that Northeastern retains the right to withdraw permission for any approved program at any time for any reason.
  8. I know that I am required to fully register with Northeastern’s Global Travel Registry.
  9. I know the conditions in my travel location(s) may change rapidly and I will stay informed of current events on a frequent, at least daily, basis by obtaining updated security and health information from and enrolling in, the U.S. State Department’s Smart Traveler Enrollment Program (STEP) at https://step.state.gov/step, which also accepts enrollment for non-U.S. citizens. I understand that non-U.S. citizens are also strongly encouraged, if possible, to register with one’s home country Embassy or Consulate and get updated information from the U.S. and home country Embassies or Consulates, as well as the DoS, CDC, and WHO websites.
  10. I understand that if conditions worsen, I may be required to return to the U.S. before completing my Program and/or travel at the sole discretion of Northeastern. I understand that in such an instance I may not receive academic credit or a refund of tuition or any other fees paid for the program and may incur additional personal and/or travel expenses.
  11. I hereby acknowledge that I have discussed my travel with at least one of my parents, guardians, or next of kin who has also read and signed this form as indicated below.
  12. I agree that the validity, construction, interpretation and all other matters relating to this Agreement shall be governed by and interpreted in accordance with the laws of the Commonwealth of Massachusetts, without regard to its conflict of law principles.  In the event of any action or proceeding to enforce any term of this Agreement, the parties shall submit to the exclusive venue of any court located in Suffolk County, Massachusetts.  I expressly agree that this Agreement, waiver, and release is intended to be as broad and inclusive as permitted under Massachusetts law and that if any portion hereof is held invalid, the balance shall continue in full legal force and effect.     
  13. WAIVER AND RELEASE OF CLAIMS. I hereby release, waive, discharge and covenant not to sue Northeastern University, its trustees, officers, agents, faculty and/or employees (hereinafter referred to as “releases”) from any and all liability, claims, demands, actions, and causes of action whatsoever arising out of or relating to any loss, damage or injury, including permanent injury and/or death, that may be sustained by me in connection with travel and/or study at the travel location(s) described above. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including permanent injury and/or death that may be sustained by me as a result of my traveling to the travel location(s) described above. I further hereby agree to defend, indemnify and save and hold harmless the releases and each of them, from any loss, liability, damage or costs they may incur as a result of my travels. It is my express intent that this release shall bind the members of my family and spouse if I am alive, and my heirs, assigns and personal representatives, if I am deceased, and shall be deemed as a release, waiver, discharge, and covenant not to sue the above-named releases.

Electronic Signature: I understand that I am signing a legal document. By signing my name below, I am performing the same task as though I were signing on paper and hold legal responsibility for signing this document. 

By signing my name below, I:

  • Certify that the information provided in the high risk travel petition form is true and correct to the best of my knowledge,
  •  Acknowledge the risk of this proposed travel,
  • Understand travel to high-risk locations is strictly voluntary,
  • Acknowledge that in the event of approval of this petition, the university retains the right to withdraw approval and require me to depart from the high-risk location at any time,
  • Have registered with STEP or citizen service from my country of origin (if applicable), and
  • Understand that the decision of the GSSAC on this request is final.
  • In connection with my travel to the Program and Travel Locations referenced above, and any other related travel, including, without limitation, personal travel for the purpose of education, personal business, social service or other experience, I acknowledge that I have carefully read this Agreement and fully understand its contents. I acknowledge that I am voluntarily executing this Agreement of my own free will. I represent and warrant that I have the authority to execute and deliver this Agreement on my behalf.

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Signature Certificate
Document name: Exception Petition Agreement for Individual Travelers - Standalone
lock iconUnique Document ID: c3a7a3ec3aad39c31c15a288495d6dc883424bfc
Timestamp Audit
May 11, 2018 11:58 am EDTException Petition Agreement for Individual Travelers - Standalone Uploaded by ISO on behalf of ISSAC - MYTRAVELPLANS@northeastern.edu IP 73.186.253.206
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