Walla Walla University

Student Missions Consent Form


Release of Confidential Information

Name*

I, _______________________, hereby authorize the Walla Walla University (WWU) Student Missions office to receive and to release information obtained in confidence from me or retained in confidence about me, for the purposes and with the limitations indicated below, in connection with my application and service as a student missionary. Choosing not to allow release of information will hinder processing of application. 

Individual/Office/AgencyPurposeRelease Limited To

WWU Student Administration Application screening Any disciplinary/citizenship issues affecting application 

WWU Deans and Resident Assistants Application screening Evaluation of fitness and ability to serve as SM 

WWU Academic Vice President Application screening Evaluation of fitness and ability to serve as SM 

WWU Counseling Resource Center Application screening Evaluation of fitness and ability to serve as SM 

WWU Academic Records Office Application screening High School/University transcripts and grades 

WWU Student Financial Services Travel authorization Status of student account 

WWU Campus Health or my physician GC application Health certificate  

HIV testing Lab/Agency/Physician Visa/entry permit HIV test results (only for countries that require) 

College Place Police or other police Visa/entry permit Police clearance letter 

WWU Accounting/ WWU Development Fundraising assessment Status of SM account/donor information 

I hereby authorize the WWU Student Missions Office to release information to the following for the purpose of SM placement, travel and support in the field: 

I hereby authorize the WWU Student Missions Office to release information to the following for the purpose of SM placement, travel and support in the field: 

Individual/Office/AgencyRelease Limited To

Parent(s)/Guardian(s)Financial and travel information, terms of service, contact information, application and volunteer status.

NAD, GC, prospective SM employerSM applications and recommendations, police clearance, health evaluation reports, and/or supervisor HIV test results, university transcript, TB test results
NAD, GC, and WWU SM OfficeContact information, photos, emails, etc. for WWU SM webpage
NAD, GC, and WWU SM OfficePhotos, stories, etc. for publication, blog information, email, Facebook page
WWU Mask and Online MaskPhotos and SM contact information

I understand that my express consent is required to release any health care information related to testing, diagnosis, and/or treatment for HIV/AIDS, sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use. The Student Missions Office is specifically authorized to release and receive all health care information relating to such diagnosis, testing and/or treatment. 

This authorization conforms with Federal regulations promulgated under 43 CFR, Part 2, Sub-part C and WAC 275-56-240. Records obtained as authorized by this consent for information release will be maintained in accordance with Federal confidentiality regulation (42 CFR, part 2) which prohibits further disclosure without written consent of the person to whom it pertains or other permitted by 43 CFR, part 2. 

I understand that I may cancel this consent at any time to the extent that action has already been taken as authorized by this release. Unless earlier canceled, this consent shall expire when I return from my term of service as an SM and my SM accounts and records are cleared. This consent for release covers all information contained in my SM applications and file. 


Financial Information and Policies 

I, ________________________, understand I am responsible for 

Student Missions travel expenses: I understand that I am responsible to pay for all expenses related to my student missions experience, including but not limited to the application fee, health evaluation, airfare, passport, visa or entry documents, immunizations, and living expenses (if not provided by my host organization) no later than 10 days prior to my departure unless express permission is granted by the Student Missions office to postpone payment.  

Fundraising Goals: I understand my fundraising goal depends on my desired location, length of service, and date of application completions. The usual goal for Domestic calls is: $500, the usual goal for funded international calls is: $3,500, and the usual goal for self-funded international calls is: $5,500. 

School Bill: I understand that my Walla Walla University student account must be paid cleared before I will be authorized to depart for my Student Missions assignment. 

Application Fee or SM Fee: I understand that a $500 SM fee is included in the fundraising goals listed above. These fees go toward training and support offered by the SM office and not directly toward the purchase of my ticket and or living expenses as an SM.  

Fundraising: I intend to raise funds by mailing fundraising letters to pay for my SM expenses. I will pay the difference between my fundraising account balance and my total Student Missions expenses, including application fees and all other fees and charges, no later than 10 days prior to my departure unless express permission is given by the Student Missions office to postpone payment. I understand that all funds raised are donations to the Student Missions office of WWU, and subject to the Chaplain's Office Executive Committee for allocation. The money does not personally belong to me, nor can it be allocated at my discretion. For any special funding requests, I must petition the Chaplain's Office Executive Committee.  

Excess Funds: I understand that excess funds can be used only for approved SM travel, helping other SMs to go, emergency expenses, and special support for SMs in the field, not for personal projects, personal travel, donations to schools, etc.. 

Travel Scholarships: I understand that I may be eligible for travel scholarships if I meet the requirements stipulated by the Student Missions office. All scholarships are subject to the Chaplain's Office Executive Committee. 

Tuition Scholarships: I understand that I may be eligible for a tuition scholarship if I meet the following requirements. All scholarships are subject to the Chaplain's Office Executive Committee.  

Tuition Scholarship Criteria: 

  •      Successful completion of at least 4.5 months of service 
  •      Successful reenrollment to WWU 
  •      Complete payment of SM fees and expenses 
  •      Completion of required classes for service 
  •      Participation in the entire SM Spring retreat 
  •      Participation in the SM Dedication Vespers Spring quarter 
  •      Participation in the SM Re-Entry Retreat fall quarter 
  •      Completion of any other necessary assignments determined by the Chaplain's Office.  

 

Health 

I, ______________________, understand that I am responsible for consulting with my health provider regarding all the necessary immunizations for my country of service. I also take full responsibility for discussing any limitations with my health provider with regards to my ability to serve. I will communicate any necessary information with the Student Mission's office, as well as my host country to serve safely. 

 

Date*
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