ISSJS.2014. Teac Experie The 2014 Teaching for Peace as professionals and activis educational efforts and inter ELIGIBILITY Applicants should be curr and/or professional or activ Applicants will be selected Purpose. STATEMENT OF PURPOSE Please complete a thoughtful st understanding your area of planning our coursework attendees facilitating your ability to th In 1000 words, please addres 1) Specific interest in nonvio nonviolence. What do you a 2) Relevant background exp background, and experien generally, and in the study o 3) Area/s of application: Wh nonviolence to? For exampl Workplace dynamics? Outre 4) Educator enrichment: How PERSONAL INFORMATION Name (First, Middle, Last) (Also include Mr./Mrs./Ms./Dr./P Address: (Residence) Street Address City State INTERNATIO ching for Peace: An Indian Im ence in Practical Nonviolence e Program invites applications from K-12 sts who want to explore the role of non ractions. rently employed or engaged in educational vist organizations. d based on the four criteria described in the b tatement of purpose to assist us in the followi f practical application/personal interest in the k emphasis and outings to make the pro hrive in the Indian education context ss the following in your Statement: olence. Please describe your specific intere already know (if anything), and what do you h perience: What aspects of your past e nces best prepare you to flourish in the In of nonviolence specifically? hat specific application area/s will you con le: Bullying? Curriculum development? Classr each and education strategies? w do you hope this program will enrich you as :_________________________________________ Prof.) :_________________________________________ :_________________________________________ :_________________________________________ :_________________________________________ ONAL SCHOOL FOR JA mmersion e educators, as well nviolence in their efforts in schools, below Statement of ing areas: e program ogram relevant for est in the study of hope to learn? education, training ndian environment nnect the study of room management? s an educator? _____ _____ _____ _____ _____ AIN STUDIES
Transcript
ISSJS.2014. Teaching for Peace: An Indian ImmersionExperience in Practical Nonviolence
The 2014 Teaching for Peace Program invites applications from K-12 educators, as wellas professionals and activists who want to explore the role of nonviolence in theireducational efforts and interactions.
ELIGIBILITY
Applicants should be currently employed or engaged in educational efforts in schools,and/or professional or activist organizations. Applicants will be selected based on the four criteria described in the below Statement ofPurpose.STATEMENT OF PURPOSEPlease complete a thoughtful statement of purpose to assist us in the following areas: understanding your area of practical application/personal interest in the program planning our coursework emphasis and outings to make the program relevant forattendees facilitating your ability to thrive in the Indian education contextIn 1000 words, please address the following in your Statement:1) Specific interest in nonviolence. Please describe your specific interest in the study ofnonviolence. What do you already know (if anything), and what do you hope to learn?2) Relevant background experience: What aspects of your past education, trainingbackground, and experiences best prepare you to flourish in the Indian environmentgenerally, and in the study of nonviolence specifically?3) Area/s of application: What specific application area/s will you connect the study ofnonviolence to? For example: Bullying? Curriculum development? Classroom management?Workplace dynamics? Outreach and education strategies?4) Educator enrichment: How do you hope this program will enrich you as an educator?PERSONAL INFORMATIONName (First, Middle, Last) :_____________________________________________(Also include Mr./Mrs./Ms./Dr./Prof.)Address: (Residence) :_____________________________________________Street Address :_____________________________________________City :_____________________________________________State :_____________________________________________
INTERNATIONAL SCHOOL FOR JAIN STUDIES
ISSJS.2014. Teaching for Peace: An Indian ImmersionExperience in Practical Nonviolence
The 2014 Teaching for Peace Program invites applications from K-12 educators, as wellas professionals and activists who want to explore the role of nonviolence in theireducational efforts and interactions.
ELIGIBILITY
Applicants should be currently employed or engaged in educational efforts in schools,and/or professional or activist organizations. Applicants will be selected based on the four criteria described in the below Statement ofPurpose.STATEMENT OF PURPOSEPlease complete a thoughtful statement of purpose to assist us in the following areas: understanding your area of practical application/personal interest in the program planning our coursework emphasis and outings to make the program relevant forattendees facilitating your ability to thrive in the Indian education contextIn 1000 words, please address the following in your Statement:1) Specific interest in nonviolence. Please describe your specific interest in the study ofnonviolence. What do you already know (if anything), and what do you hope to learn?2) Relevant background experience: What aspects of your past education, trainingbackground, and experiences best prepare you to flourish in the Indian environmentgenerally, and in the study of nonviolence specifically?3) Area/s of application: What specific application area/s will you connect the study ofnonviolence to? For example: Bullying? Curriculum development? Classroom management?Workplace dynamics? Outreach and education strategies?4) Educator enrichment: How do you hope this program will enrich you as an educator?PERSONAL INFORMATIONName (First, Middle, Last) :_____________________________________________(Also include Mr./Mrs./Ms./Dr./Prof.)Address: (Residence) :_____________________________________________Street Address :_____________________________________________City :_____________________________________________State :_____________________________________________
INTERNATIONAL SCHOOL FOR JAIN STUDIES
ISSJS.2014. Teaching for Peace: An Indian ImmersionExperience in Practical Nonviolence
The 2014 Teaching for Peace Program invites applications from K-12 educators, as wellas professionals and activists who want to explore the role of nonviolence in theireducational efforts and interactions.
ELIGIBILITY
Applicants should be currently employed or engaged in educational efforts in schools,and/or professional or activist organizations. Applicants will be selected based on the four criteria described in the below Statement ofPurpose.STATEMENT OF PURPOSEPlease complete a thoughtful statement of purpose to assist us in the following areas: understanding your area of practical application/personal interest in the program planning our coursework emphasis and outings to make the program relevant forattendees facilitating your ability to thrive in the Indian education contextIn 1000 words, please address the following in your Statement:1) Specific interest in nonviolence. Please describe your specific interest in the study ofnonviolence. What do you already know (if anything), and what do you hope to learn?2) Relevant background experience: What aspects of your past education, trainingbackground, and experiences best prepare you to flourish in the Indian environmentgenerally, and in the study of nonviolence specifically?3) Area/s of application: What specific application area/s will you connect the study ofnonviolence to? For example: Bullying? Curriculum development? Classroom management?Workplace dynamics? Outreach and education strategies?4) Educator enrichment: How do you hope this program will enrich you as an educator?PERSONAL INFORMATIONName (First, Middle, Last) :_____________________________________________(Also include Mr./Mrs./Ms./Dr./Prof.)Address: (Residence) :_____________________________________________Street Address :_____________________________________________City :_____________________________________________State :_____________________________________________
INTERNATIONAL SCHOOL FOR JAIN STUDIES
Zip Code :_____________________________________________Country :_____________________________________________Phone No. :_____________________________________________Cell No. :_____________________________________________Email :_____________________________________________Date of Birth :_____________________________________________Age :_____________________________________________Gender (Male/Female) :_____________________________________________Nationality :_____________________________________________Language Accent :_____________________________________________
Teaching and Other Experience
Particulars Institution 1 Institution 2 Institution 3Current Place of EmploymentStreetCityStateZip CodeCountryPosition(Teaching/Nonteaching)Grade Levels TaughtSubject(s) TaughtTotal years of experience as ateacher
Did you ever travel or stay in India?
Particulars Visit 1 Visit 2 Visit 3DurationYearPurposeHow did you learn about ISJS program?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Statement of purpose:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________For more information or any questions or concern, please contact our teacher coordinatorMs. Laura HirshfieldTeacher, Department of EnglishActon Public SchoolsEmail: [email protected]
Website: www.isjs.in
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)Liability Waiver, 2014 (ISJS, INDIA)
Name (last, first, middle): ___________________________________________________________
_________________________________________________________________________I understand that traveling to and attending the Jain Summer School Program (“Program”) in India
conducted by International School for Jain Studies (INDIA). may involve certain risks, including but notlimited to risks inherent in international travel, such as sickness, illnesses, exhaustions (mental and physical),accidents, emergencies, exposure to reckless conduct of other persons, sexual harassment, rape, murder,assault, kidnapping and/or lack of adequate facilities and support systems offered by ISJS, (INDIA) and theirmanagement associate.
ISJS (INDIA) will not accept any liability for injury (Mental, Emotional, Verbal And Physical), loss,damage or expense sustained as a result of my participation in the Program, prior to, during and after theparticipation in the Program and I accept that none of the organizers and supporters ISJS, India will be heldresponsible in any form and shape....
Further, it is always possible that the Program may not be completed or individual activities may becurtailed or cancelled. Reasons for curtailment or cancellation may include, but are not limited to: weather,illness, terrorism, political disturbances, transportation problems, failure to perform on the part of travelagents or airlines, problems relating to customs, or other circumstances beyond the control of ISJS, India. It isthe responsibility of each Participant in the Program to learn as much as possible about the risks of theventure, to weigh those risks against the advantages, and to decide whether or not to participate.
The ISJS, India, its governors, officers, employees, volunteers, students and representatives, and anyindividuals and organizers connected with the Program accept no responsibility and assume no liabilitywhatsoever with respect to any academic, vocational, medical, physical, emotional or financial consequencesand advice received by a Participant.
While a participant in this program, I agree to not engage in any unlawful (criminal and civil)activities, break any laws of the home and host countries, and engage in any political or undesirable activities.
INTERNATIONAL SCHOOL FOR JAIN STUDIES
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)Liability Waiver, 2014 (ISJS, INDIA)
Name (last, first, middle): ___________________________________________________________
_________________________________________________________________________I understand that traveling to and attending the Jain Summer School Program (“Program”) in India
conducted by International School for Jain Studies (INDIA). may involve certain risks, including but notlimited to risks inherent in international travel, such as sickness, illnesses, exhaustions (mental and physical),accidents, emergencies, exposure to reckless conduct of other persons, sexual harassment, rape, murder,assault, kidnapping and/or lack of adequate facilities and support systems offered by ISJS, (INDIA) and theirmanagement associate.
ISJS (INDIA) will not accept any liability for injury (Mental, Emotional, Verbal And Physical), loss,damage or expense sustained as a result of my participation in the Program, prior to, during and after theparticipation in the Program and I accept that none of the organizers and supporters ISJS, India will be heldresponsible in any form and shape....
Further, it is always possible that the Program may not be completed or individual activities may becurtailed or cancelled. Reasons for curtailment or cancellation may include, but are not limited to: weather,illness, terrorism, political disturbances, transportation problems, failure to perform on the part of travelagents or airlines, problems relating to customs, or other circumstances beyond the control of ISJS, India. It isthe responsibility of each Participant in the Program to learn as much as possible about the risks of theventure, to weigh those risks against the advantages, and to decide whether or not to participate.
The ISJS, India, its governors, officers, employees, volunteers, students and representatives, and anyindividuals and organizers connected with the Program accept no responsibility and assume no liabilitywhatsoever with respect to any academic, vocational, medical, physical, emotional or financial consequencesand advice received by a Participant.
While a participant in this program, I agree to not engage in any unlawful (criminal and civil)activities, break any laws of the home and host countries, and engage in any political or undesirable activities.
INTERNATIONAL SCHOOL FOR JAIN STUDIES
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)Liability Waiver, 2014 (ISJS, INDIA)
Name (last, first, middle): ___________________________________________________________
_________________________________________________________________________I understand that traveling to and attending the Jain Summer School Program (“Program”) in India
conducted by International School for Jain Studies (INDIA). may involve certain risks, including but notlimited to risks inherent in international travel, such as sickness, illnesses, exhaustions (mental and physical),accidents, emergencies, exposure to reckless conduct of other persons, sexual harassment, rape, murder,assault, kidnapping and/or lack of adequate facilities and support systems offered by ISJS, (INDIA) and theirmanagement associate.
ISJS (INDIA) will not accept any liability for injury (Mental, Emotional, Verbal And Physical), loss,damage or expense sustained as a result of my participation in the Program, prior to, during and after theparticipation in the Program and I accept that none of the organizers and supporters ISJS, India will be heldresponsible in any form and shape....
Further, it is always possible that the Program may not be completed or individual activities may becurtailed or cancelled. Reasons for curtailment or cancellation may include, but are not limited to: weather,illness, terrorism, political disturbances, transportation problems, failure to perform on the part of travelagents or airlines, problems relating to customs, or other circumstances beyond the control of ISJS, India. It isthe responsibility of each Participant in the Program to learn as much as possible about the risks of theventure, to weigh those risks against the advantages, and to decide whether or not to participate.
The ISJS, India, its governors, officers, employees, volunteers, students and representatives, and anyindividuals and organizers connected with the Program accept no responsibility and assume no liabilitywhatsoever with respect to any academic, vocational, medical, physical, emotional or financial consequencesand advice received by a Participant.
While a participant in this program, I agree to not engage in any unlawful (criminal and civil)activities, break any laws of the home and host countries, and engage in any political or undesirable activities.
INTERNATIONAL SCHOOL FOR JAIN STUDIES
Furthermore, while participating in this program and meeting with Jain monks, nuns, lay Jains andother people; and while visiting places of worship and religious sites and also in food, I will strive to showrespect and regards and observe the necessary customs and the traditions of the sponsors of this program.
I agree that I will fully and willingly participate in all the academic and other activities of the programand observe all the discipline for the proper functioning of ISSJS. If I fail to observe the academic and otherdiscipline, ISJS India, organizer is free to ask me to leave the program at any stage during the programwithout any compensation.
I give permission to ISJS India, its affiliates and supporters to use any of my written and/verbalcomments and/or photographs in which I appear as a participant in the ISSJS Program (“Program”) for publicrelations and/or fund-raising purposes (including letters, brochures, magazine advertisements, web sites,videos, emails, and public and private talks etc.) without any remuneration, compensation, prior permission,acknowledgements and recognition.
I am participating in this International Summer School for Jain Studies 2014 program knowing of allthe risks at my own free will without any coercion, force or promises of any kind by any one.
I have been briefed and also read carefully the scholars hand bole, and made myself covers out withthe program and arrangements.
I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND IT’S CONTENT. I AMAWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT, AND I SIGN IT OF MY OWN FREEWILL. I FULLY UNDERSTAND THAT BY SIGNING THIS I AM RELEASING ISJS INDIA AND ALL ITSAFFILIATES FROM ANY CLAIMS OR RESPONSIBILITY AS SET FORTH ABOVE LEGALLY OROTHERWISE AND CONSENT TO THE STATEMENTS AND POLICIES MENTIONED ABOVE.__________________________________ ________________________________________Signature of Applicant Date__________________________________ ________________________________________Witness (1) signature (also write full name) Date
Full Name & Add:
Witness (2) signature (also write full name) Date
Full Name & Add:
Please mail this form to the following address by February 28th 2014:
The Office of Director of Admissions, ISSJSD-28 Panchsheel EnclaveNew Delhi-110 017 (INDIA)Email: [email protected]
(Or electronically after scanning the filled form and attaching to the application to [email protected])
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)Liability Waiver, 2014 (MVI, USA)
Name (last, first, middle): _____________________________________________________
I understand that traveling to and attending the Jain Summer School Program (“Program”) in India conductedby offered by Mahavir Vision, Inc & Jain Academic Foundation of North America (JAFNA). mayinvolve certain risks, including but not limited to risks inherent in international travel, such as sickness,illnesses, exhaustions (mental and physical), accidents, emergencies, exposure to reckless conduct of otherpersons, sexual harassment, rape, murder, assault, kidnapping and/or lack of adequate facilities and supportsystems by any of the providers, Mahavir Vision, Inc., directors, employees, volunteers, agents, sponsors,supporters and all affiliate organizations of the ISSJS program in North America, Europe and India.
The ISSJS and Mahavir Vision, Inc., will not accept any liability for injury (Mental, Emotional,Verbal And Physical), loss, damage or expense sustained as a result of my participation in the Program, priorto, during and after the participation in the Program and I accept that none of the organizers and supporters(Mahavir Vision, Inc., ISSJS and others) will be held responsible in any form and shape....
Further, it is always possible that the Program may not be completed or individual activities may becurtailed or cancelled. Reasons for curtailment or cancellation may include, but are not limited to: weather,illness, terrorism, political disturbances, transportation problems, failure to perform on the part of travelagents or airlines, problems relating to customs, or other circumstances beyond the control of Mahavir Vision,Inc. It is the responsibility of each Participant in the Program to learn as much as possible about the risks ofthe venture, to weigh those risks against the advantages, and to decide whether or not to participate.
The Mahavir Vision, Inc., its governors, officers, employees, volunteers, students and representatives,and any individuals and organizers connected with the Program accept no responsibility and assume noliability whatsoever with respect to any academic, vocational, medical, physical, emotional or financialconsequences and advice received by a Participant.
While a participant in this program, I agree to not engage in any unlawful (criminal and civil)activities, break any laws of the home and host countries, and engage in any political or undesirable activities.
INTERNATIONAL SCHOOL FOR JAIN STUDIES
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)Liability Waiver, 2014 (MVI, USA)
Name (last, first, middle): _____________________________________________________
I understand that traveling to and attending the Jain Summer School Program (“Program”) in India conductedby offered by Mahavir Vision, Inc & Jain Academic Foundation of North America (JAFNA). mayinvolve certain risks, including but not limited to risks inherent in international travel, such as sickness,illnesses, exhaustions (mental and physical), accidents, emergencies, exposure to reckless conduct of otherpersons, sexual harassment, rape, murder, assault, kidnapping and/or lack of adequate facilities and supportsystems by any of the providers, Mahavir Vision, Inc., directors, employees, volunteers, agents, sponsors,supporters and all affiliate organizations of the ISSJS program in North America, Europe and India.
The ISSJS and Mahavir Vision, Inc., will not accept any liability for injury (Mental, Emotional,Verbal And Physical), loss, damage or expense sustained as a result of my participation in the Program, priorto, during and after the participation in the Program and I accept that none of the organizers and supporters(Mahavir Vision, Inc., ISSJS and others) will be held responsible in any form and shape....
Further, it is always possible that the Program may not be completed or individual activities may becurtailed or cancelled. Reasons for curtailment or cancellation may include, but are not limited to: weather,illness, terrorism, political disturbances, transportation problems, failure to perform on the part of travelagents or airlines, problems relating to customs, or other circumstances beyond the control of Mahavir Vision,Inc. It is the responsibility of each Participant in the Program to learn as much as possible about the risks ofthe venture, to weigh those risks against the advantages, and to decide whether or not to participate.
The Mahavir Vision, Inc., its governors, officers, employees, volunteers, students and representatives,and any individuals and organizers connected with the Program accept no responsibility and assume noliability whatsoever with respect to any academic, vocational, medical, physical, emotional or financialconsequences and advice received by a Participant.
While a participant in this program, I agree to not engage in any unlawful (criminal and civil)activities, break any laws of the home and host countries, and engage in any political or undesirable activities.
INTERNATIONAL SCHOOL FOR JAIN STUDIES
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)Liability Waiver, 2014 (MVI, USA)
Name (last, first, middle): _____________________________________________________
I understand that traveling to and attending the Jain Summer School Program (“Program”) in India conductedby offered by Mahavir Vision, Inc & Jain Academic Foundation of North America (JAFNA). mayinvolve certain risks, including but not limited to risks inherent in international travel, such as sickness,illnesses, exhaustions (mental and physical), accidents, emergencies, exposure to reckless conduct of otherpersons, sexual harassment, rape, murder, assault, kidnapping and/or lack of adequate facilities and supportsystems by any of the providers, Mahavir Vision, Inc., directors, employees, volunteers, agents, sponsors,supporters and all affiliate organizations of the ISSJS program in North America, Europe and India.
The ISSJS and Mahavir Vision, Inc., will not accept any liability for injury (Mental, Emotional,Verbal And Physical), loss, damage or expense sustained as a result of my participation in the Program, priorto, during and after the participation in the Program and I accept that none of the organizers and supporters(Mahavir Vision, Inc., ISSJS and others) will be held responsible in any form and shape....
Further, it is always possible that the Program may not be completed or individual activities may becurtailed or cancelled. Reasons for curtailment or cancellation may include, but are not limited to: weather,illness, terrorism, political disturbances, transportation problems, failure to perform on the part of travelagents or airlines, problems relating to customs, or other circumstances beyond the control of Mahavir Vision,Inc. It is the responsibility of each Participant in the Program to learn as much as possible about the risks ofthe venture, to weigh those risks against the advantages, and to decide whether or not to participate.
The Mahavir Vision, Inc., its governors, officers, employees, volunteers, students and representatives,and any individuals and organizers connected with the Program accept no responsibility and assume noliability whatsoever with respect to any academic, vocational, medical, physical, emotional or financialconsequences and advice received by a Participant.
While a participant in this program, I agree to not engage in any unlawful (criminal and civil)activities, break any laws of the home and host countries, and engage in any political or undesirable activities.
INTERNATIONAL SCHOOL FOR JAIN STUDIES
Furthermore, while participating in this program and meeting with Jain monks, nuns, lay Jains andother people; and while visiting places of worship and religious sites and also in food, I will strive to showrespect and regards and observe the necessary customs and the traditions of the sponsors of this program.
I agree that I will fully and willingly participate in all the academic and other activities of the programand observe all the discipline for the proper functioning of ISSJS. If I fail to observe the academic and otherdiscipline, ISJS India, organizer is free to ask me to leave the program at any stage during the programwithout any compensation.
I give permission to Mahavir Vision, Inc., its affiliates and supporters to use any of my writtenand/verbal comments and/or photographs in which I appear as a participant in the ISSJS Program(“Program”) for public relations and/or fund-raising purposes (including letters, brochures, magazineadvertisements, web sites, videos, emails, and public and private talks etc.) without any remuneration,compensation, prior permission, acknowledgements and recognition.
I am participating in this International Summer School for Jain Studies 2014 program knowing of allthe risks at my own free will without any coercion, force or promises of any kind by any one.
I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND IT’S CONTENT.I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT, AND I SIGN IT OFMY OWN FREE WILL. I FULLY UNDERSTAND THAT BY SIGNING THIS I AM RELEASING ISJSINDIA AND ALL ITS AFFILIATES FROM ANY CLAIMS OR RESPONSIBILITY AS SET FORTHABOVE LEGALLY OR OTHERWISE AND CONSENT TO THE STATEMENTS AND POLICIESMENTIONED ABOVE.__________________________________ ________________________________________Signature of Applicant Date__________________________________ ________________________________________Witness (1) signature (also write full name) Date
Witness (2) signature (also write full name) Date
Please mail this form to the following address by February 28th 2014:The Office of Director of Admissions, ISSJSD-28 Panchsheel EnclaveNew Delhi-110 017 (INDIA)Email: [email protected](Or electronically after scanning the filled form and attaching to the application to [email protected])
Website: www.isjs.inWebsite: www.isjs.in
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)
PARTICIPANT DATA FOR MEDICAL BACKGROUNDPassport Number : ______________________________________________Passport Issue Date : ______________________________________________Passport Expiration Date : ______________________________________________Place of Issue : ______________________________________________MEDICAL INSURANCE
Note: Please check with your medical Insurance provider to determine whether you have aMedical coverage in India. You will be responsible for all costs of medical care (includinghospitalization) needed in India or after you return from your study trip in India. The ISSJSDirector in India will make referrals regarding physicians and hospitals, but you (not thesponsors of this Study Program) will be asked to pay directly to the service providers in India.If your medical insurance provider does not cover internationally, you will need to purchasetravel insurance. Please see the pre-departure travel brochure for more information.Address: __________________________________________________________________________________________________Primary Policy Holder: __________________________________________________________________________________Type of coverage: ________________________________________________________________________________________Phone: ____________________________________________ Email: ________________________________________________I have read the statements concerning health and medical Insurance, and I understand themfully. I agree to sign the indemnity and general agreement with the sponsors. I further certifythat all of the Information I have provided on this application is true, complete, and accurate,to the best of my knowledge.Signature:Date:Printed Name:
INTERNATIONAL SCHOOL FOR JAIN STUDIES
Website: www.isjs.inWebsite: www.isjs.in
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)
PARTICIPANT DATA FOR MEDICAL BACKGROUNDPassport Number : ______________________________________________Passport Issue Date : ______________________________________________Passport Expiration Date : ______________________________________________Place of Issue : ______________________________________________MEDICAL INSURANCE
Note: Please check with your medical Insurance provider to determine whether you have aMedical coverage in India. You will be responsible for all costs of medical care (includinghospitalization) needed in India or after you return from your study trip in India. The ISSJSDirector in India will make referrals regarding physicians and hospitals, but you (not thesponsors of this Study Program) will be asked to pay directly to the service providers in India.If your medical insurance provider does not cover internationally, you will need to purchasetravel insurance. Please see the pre-departure travel brochure for more information.Address: __________________________________________________________________________________________________Primary Policy Holder: __________________________________________________________________________________Type of coverage: ________________________________________________________________________________________Phone: ____________________________________________ Email: ________________________________________________I have read the statements concerning health and medical Insurance, and I understand themfully. I agree to sign the indemnity and general agreement with the sponsors. I further certifythat all of the Information I have provided on this application is true, complete, and accurate,to the best of my knowledge.Signature:Date:Printed Name:
INTERNATIONAL SCHOOL FOR JAIN STUDIES
Website: www.isjs.inWebsite: www.isjs.in
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)
PARTICIPANT DATA FOR MEDICAL BACKGROUNDPassport Number : ______________________________________________Passport Issue Date : ______________________________________________Passport Expiration Date : ______________________________________________Place of Issue : ______________________________________________MEDICAL INSURANCE
Note: Please check with your medical Insurance provider to determine whether you have aMedical coverage in India. You will be responsible for all costs of medical care (includinghospitalization) needed in India or after you return from your study trip in India. The ISSJSDirector in India will make referrals regarding physicians and hospitals, but you (not thesponsors of this Study Program) will be asked to pay directly to the service providers in India.If your medical insurance provider does not cover internationally, you will need to purchasetravel insurance. Please see the pre-departure travel brochure for more information.Address: __________________________________________________________________________________________________Primary Policy Holder: __________________________________________________________________________________Type of coverage: ________________________________________________________________________________________Phone: ____________________________________________ Email: ________________________________________________I have read the statements concerning health and medical Insurance, and I understand themfully. I agree to sign the indemnity and general agreement with the sponsors. I further certifythat all of the Information I have provided on this application is true, complete, and accurate,to the best of my knowledge.Signature:Date:Printed Name:
INTERNATIONAL SCHOOL FOR JAIN STUDIES
Website: www.isjs.inWebsite: www.isjs.in
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)
PARTICIPANT DATA IN CASE OF EMERGENCYThe sole of purpose of the following data is for emergency use only. It will not be used for anyother purpose.Your Information:Name: (First, Middle, Last): _____________________________________________________________________________Name of Spouse: _________________________________________________________________________________________Spouse Address Street /P.O. Box: ______________________________________________________________________City: __________________State/Province: _____________ Postal Code: ______________Country: _____________Home Phone: ___________________________________Cell Phone: ____________________________________________Fax: ____________________________________________Email Address: _________________________________________Name of Employer, if any: _______________________________________________________________________________Permanent Contact Information (if different from above): __________________________________________Name of primary resident (if not yours): ______________________________________________________________Street Address/P.O. Box: ________________________________________________________________________________City: __________________State/Province: _____________ Postal Code: ______________Country: _____________Home Phone ___________________________________ Email address: ________________________________________Dietary Restrictions, if any:Allergies/Current Medications, If any:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
INTERNATIONAL SCHOOL FOR JAIN STUDIES
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)
PARTICIPANT DATA IN CASE OF EMERGENCYThe sole of purpose of the following data is for emergency use only. It will not be used for anyother purpose.Your Information:Name: (First, Middle, Last): _____________________________________________________________________________Name of Spouse: _________________________________________________________________________________________Spouse Address Street /P.O. Box: ______________________________________________________________________City: __________________State/Province: _____________ Postal Code: ______________Country: _____________Home Phone: ___________________________________Cell Phone: ____________________________________________Fax: ____________________________________________Email Address: _________________________________________Name of Employer, if any: _______________________________________________________________________________Permanent Contact Information (if different from above): __________________________________________Name of primary resident (if not yours): ______________________________________________________________Street Address/P.O. Box: ________________________________________________________________________________City: __________________State/Province: _____________ Postal Code: ______________Country: _____________Home Phone ___________________________________ Email address: ________________________________________Dietary Restrictions, if any:Allergies/Current Medications, If any:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
INTERNATIONAL SCHOOL FOR JAIN STUDIES
INTERNATIONAL SUMMER SCHOOL FOR JAIN STUDIES (ISSJS)
PARTICIPANT DATA IN CASE OF EMERGENCYThe sole of purpose of the following data is for emergency use only. It will not be used for anyother purpose.Your Information:Name: (First, Middle, Last): _____________________________________________________________________________Name of Spouse: _________________________________________________________________________________________Spouse Address Street /P.O. Box: ______________________________________________________________________City: __________________State/Province: _____________ Postal Code: ______________Country: _____________Home Phone: ___________________________________Cell Phone: ____________________________________________Fax: ____________________________________________Email Address: _________________________________________Name of Employer, if any: _______________________________________________________________________________Permanent Contact Information (if different from above): __________________________________________Name of primary resident (if not yours): ______________________________________________________________Street Address/P.O. Box: ________________________________________________________________________________City: __________________State/Province: _____________ Postal Code: ______________Country: _____________Home Phone ___________________________________ Email address: ________________________________________Dietary Restrictions, if any:Allergies/Current Medications, If any:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
INTERNATIONAL SCHOOL FOR JAIN STUDIES
In Case emergency, notify: ______________________________________________________________________________I give permission to Mahavir Vision Inc. and its affiliates to use any of my written commentsand/or photographers in which I appear as a participant in the program for public relationsand/or fundraising purpose (including brochures, magazine advertisements, web sites, videos,etc.) without remuneration.On behalf of myself and any of my personal and/or legal representatives, I hereby release TheMahavir Vision Inc. of USA, and its affiliates in USA, Europe and In India, all staff (including theprogram directors), and all individual and institutional associates of the Jain Study programfrom liability for any personal injury (such as psychological distress, physical injury, anddeath) resulting from traveling from a designated city in USA to India and also travel in Indiaby and schedule air lines, local train bus and private car and in any way stemming frompolitical conflict in India.I further agree that all organizers, organizations, facilitators, sponsors and supporters of thisJain Study Summer School 2014 program in North America, Europe and India will not be heldliable and responsible in any shape or form, implied, or otherwise directly or indirectly,intentionally unintentionally, legally and otherwise for any claims of any kind, due to thefts,loss, dispute, grievance, complaints, accidents, deaths, medical emergencies and any otherincidents, occurrences and situations arising due to participation in this Jain study programprior to, during, and after this program.By singing below, I confirm that I fully understand and constant to all the statements andPolicies listed in the above Jain study program Agreement of The Mahavir Vision Inc. and allaffiliated institutions.Signature: ______________________ Date: ______________________Printed Name: ___________________Witness (1):Printed Name: _________________________ Contact No. ______________________ Email: ______________________Address: ___________________________________________________________________________________________________________________________________________________________________________________________________Witness (2):Printed Name: _________________________ Contact No. ______________________ Email: ______________________Address: ___________________________________________________________________________________________________________________________________________________________________________________________________
