Summer Work and Travel Program Agreement

and Fees Disclosure

IMPORTANT: THIS IS A LEGALLY BINDING AGREEMENT. If you have any questions, please ask American Hospitality Academy
(hereby referred to as AHA) or your local agency (hereby referred to GRP) before you sign these Terms & Conditions. Voluntary or
willful ignorance of the content of this document will not release you from your responsibilities .

I agree to the following Terms & Conditions of my participation in the Cultural Exchange Program through AHA:

SECTION 1: Purpose of Program, Terms and Conditions Pre-Arrival

1. Important terms used throughout the J-1 cultural exchange program:

a. Exchange Visitor, Participant, Cultural Ambassador = YOU!
b. Host Employer, Host Organization, Host Property = The employer hosting your J-1 Program
c. American Hospitality Academy, AHA = Sponsor
d. GRP = Global Representative Partner, Global Recruiting Partner, County Agent, Country Representative
2. I understand the Summer Work Travel program provides foreign students with an opportunity to live and work in the United States during
their summer vacation from college or university to experience and to be exposed to the people and way of life in the United States. More
information can be found at https://j1visa.state.gov/participants and in the EVP Welcome Brochure.
3. I certify that the information contained in my application is complete, true, and accurate. I acknowledge that falsification or omission of
information is grounds for rejection of the application, or if discovered later, immediate dismissal from the program. I authorize any
person, organization or company listed on this application to furnish AHA all information concerning my previous employment, education
and qualifications for the exchange visitor program. I authorize and give consent to AHA to access my arrival and departure date records
via the U.S. Customs and Border Protection's (CBP's) Nonimmigrant Information System (NIIS), I-94 Department of Homeland Security
website.
4. I have received program information and materials that clearly explained program activities and terms, conditions and restrictions of the
program via AHA’s portal, website, host property information sheet, J-1 placement form, orientation and agreement
5. I have received terms and conditions of employment activities to include job duties, number of work hours, wages and compensation ,
and any typical deductions for housing and transportation via the host property information sheet, signed employment/placement offer.
6. I received the type, duration, nature and importance of the cultural components of the program via the host property information
sheet, AHA’s Portal and/or J-1 placement offer.
7. I understand I am expected to remain at my original host throughout the duration of my program.
8. I understand that if I quit the employment approved by AHA and as outlined on the Job Placement Form, I am resigning from the program
and my J-1 visa sponsorship will be terminated and I must return home immediately.
9. I understand I may not start work at any job (i.e., initial, subsequent, or additional) until AHA has fully vetted such jobs and give written
permission. AHA is required to terminate the programs of participants who to fail to comply with this participant obligation.
10. I understand the J-1 Visa is a non-immigrant visa and that this program is not a way to obtain a permanent job in the U.S. or a way to
immigrate. I understand I am not to attempt a change of visa status while in the U.S., I agree to return home at the conclusion of the
program per J-1 regulations.
11. Monthly Monitoring. I am required to communicate to AHA at least once per month. AHA will email me by the 1st of each month, I
agree I will respond by the 10th of each month. If I do not have access to email I will call AHA by the 10th of each month. Failure to
adhere will result in J-1 visa termination.
12. For participants accepting positions in housekeeping. I understand the position description and I am physically able to complete the
job. I am committed to complete this job for the duration of my J-1 visa program as I am not permitted to accept another position
without first seeking approval from AHA. AHA's goal to all SWT participants have an enjoyable experience and have expectations met. I
agree I have taken into consideration all factors of accepting a position in housekeeping and this position will meet my expectations.
13. I confirm I have declared any known ailments, allergies or known medical history which could affect ability to participate in the program
or the position selected. I attest that I am in good physical and mental health and to my knowledge do not have any physical or mental
conditions that could affect my ability to successfully participate in the Program.
14. I understand I must complete mandatory AHA orientation prior to arrival. Orientation, Resource Guide, SWT Job Placement Form, Host
Property information details assist and prepare me for my stay in the United States (e.g.,how and when to apply for a social security

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 number, how to apply for a driver's license; how to open a bank account; employee rights and laws, including workman's compensation;
and how to remain in lawful non-immigrant status).
15. I agree to adhere to all rules, regulations, policies, and procedures of AHA and Host Employer. I confirm I have received AHA’s Resource
Guide and understand failure to adhere to rules; regulations; policies and procedures of AHA and/or the Host Employer will result in the
termination of program sponsorship.
16. I understand I am responsible for reading and carefully considering all materials made available that relate to safety, health, legal,
environmental, political, cultural, and religious customs and conditions in the U.S. I will take full responsibility of laws, regulations, or
customs are broken, regardless of my actual knowledge of these laws, regulations, or customs.
17. I will maintain communication with AHA prior to arrival, notify AHA in advance (10 days) of arrival and promptly advise AHA of any
changes to my travel itinerary due to visa delays or any unforeseen circumstances.
18. I agree not to start my Program prior to the start date on my DS‐2019 form or beyond the end date on my DS‐2019 form. I understand
that I must return home within 30 days after the end date on my DS‐2019 form, and I may not work during that period.
19. I understand I am required to contact AHA within 24 hours of arrival and my J-1 visa will not be validated until confirmation of arrival and
USA address is completed. Failure to validate my visa will result in my program termination with no refund.
20. I understand if I need to leave the United States during the program, I must have prior authorization from AHA at least two weeks before
departure. Failure to do this will may result in the inability to re-enter the country.

SECTION 2: General Program Terms and Conditions

21. I have received and read the Legal Rights and Protections pamphlet outlining rights in the United States and protection available.
22. I understand consular officers are required to prudentially revoke (i.e., without making a determination that the individual is
inadmissible) nonimmigrant visas of individuals arrested for, or convicted of, driving under the influence or driving while intoxicated, or
similar arrests/convictions as detailed in 9 FAM 403.11-3(A).
23. I confirm I have been provided Two-year Home-Country Physical Presence Requirement information and understand I may be subject to
the two-year home-country physical presence (foreign residence) requirement.
24. I understand if I need to travel outside of the United States during the program, I must have prior authorization from AHA at least three
weeks before departure. Failure to do this will may result in the inability to re-enter the country. Travel Information
25. I agree to exercise due care once in possession of the legal documentation (DS- 2019, J-1 Visa, etc.) for the program, I will be responsible
for the cost of replacing these items.
26. I will report to AHA within ten calendar days any changes to my actual and current U.S. address, telephone number, email.
27. All travel before, during and after the program is at my own risk. I understand if I choose to operate motorized vehicles, I am responsible
for obtaining the necessary license, permission, and insurance, and does so at my own risk.
28. If during the program I encounter any difficulties with my employment, or with safety, health, housing, I agree to notify AHA as soon as
possible.
29. I agree I will not engage in any activity that would bring the Exchange Visitor Program or the U.S. Department of State into notoriety or
disrepute. I agree to contact AHA for guidance if any proposed activity might cause this result.
30. I understand if I do not comply with the rules, regulations and requirements set by AHA and host that AHA has the authority to terminate
the program early and require me to return home immediately without a refund.
31. I agree I will check emails at least once every other day and respond to all messages from AHA.
32. I understand I must complete a monthly check-in with AHA to update status and send evidence of participation in cultural activities, failure
to complete this regulatory requirement will result in my program termination.
33. I give permission to AHA to take, retain, and use any written, photographic, or video images of myself when reporting on and/or
promoting AHA programs. I hereby waive compensation and any right to inspect or approve any such uses and Reproductions. I hereby
release, discharge and agree to hold AHA harmless from any liability arising out of AHA’s use of the Reproductions, including any blurring,
distortion, alteration, optical illusion or use in composite form with other works.

SECTION 3: U.S. Host Employer

34. I understand any illegal use of drug or alcohol, or abuse of harmful controlled substances or illegal possession of drugs, alcohol, or
controlled substances will be subject to immediate termination.
35. I understand I may be required to undergo pre-employment and random drug and alcohol testing from Host Employer, failure to pass
such test will result in program termination and I will be required to return home.

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 36. I understand I am only permitted to train/work at the Host Employer listed in his or her application and on the DS-2019 form. Engaging in
unauthorized employment is a violation of the program and will result in J-1 sponsorship termination. I understand that I am not allowed
to engage in any other activity for money for the duration of my J-1 program without first receiving approval from AHA.
37. I understand I have the right to end my program at any time and AHA and/or Host Employer retains a similar right. The contents of this
Agreement and all other documents are presented as a matter of information and do not constitute a contract, expressed, or implied
between AHA and the Exchange Visitor.
38. I understand if I am terminated by the Host Employer from the program for non-compliance with the program, or the workplace rules of
the Host Employer, I will be terminated from the program. I understand AHA will not assist terminated Exchange Visitors in finding
alternative Host Employers.

SECTION 4: Financial Information

39. PROGRAM FEE DISCLOSURE: I understand there is a fee required to participate in a J-1 program and I have completed the fee disclosure
form confirming the fees paid and that I have not paid another agent or 3 rd party any additional fees that is not disclosed on this form.
40. I confirm I have sufficient financial funds to support myself throughout the program and access to at least $2000 USD in case of an
emergency as declared below on the financial disclosure portion of this document, falsifying this form will result in program termination.
At no time is AHA, host employer or third employer financially responsible for me. I agree I am solely responsible for any and all expenses
and costs incurred before, during and after the Program
41. I confirm I will purchase a round trip ticket. If purchasing a round trip ticket is not possible, I confirm I have the necessary funds available
to purchase a return ticket in the event I withdraw from my program or my program ends earlier than planned for any reason.
42. I understand wages may not cover all expenses, the purpose of the stipend/wage from host company is to assist in covering living expenses
and not to make or save money.
43. I acknowledge I received specific details on housing and expected cost. I agree I have researched the intended host city and determined I
can afford to live there based on projected monthly stipend and access to additional funds.
44. I understand I will receive the hourly rate indicated on the Job Placement form. This rate will change as I am exposed and rotated through
various positions. When I train/work in a tipped position an employer may pay a lower “tipped” rate. My Host Employer will adhere to
minimum wage laws.
45. I understand the Host Employer has agreed to schedule a minimum of 32 hours per week, scheduled hours will change as the business
demands change.

REFUND POLICY Note, the following outlines AHA’s refund policy, participants working with agent understand and agrees the agent will
disclose the agent refund policy.

46. Cancellation after documents received and moved To Be Placed: If an application is withdrawn/canceled from the program due to any
reason after candidates file moved To Be Placed, $200 application fee will be withheld.
47. Cancellation after Issuance of DRAFT DS-2019 form is emailed – NO REFUND/NO CREDIT
48. Embassy/Consulate Denial. In case of a visa denial at the US Embassy, Participant must inform AHA within 5 business days of denial and
return the original DS-2019 Form and original proof of denial from the Embassy or Consulate within 30 business days from the date of
denial to receive refunds. AHA retains $360.00
49. Cancellation After Arrival in the United States. NO REFUND/NO CREDIT If, once in the United States, Participant program is
ended/canceled due to any reason to include but not limited to: personal choice, host ending the program (laid off, termination), an official
decision of the local government, American government, no refund is issued regardless of the length of time remaining for the scheduled
program.
50. AHA recommends participants to research and consider Trip Interruption Insurance as there is no exception to the refund policy

SECTION 5: Insurance
51. I understand as part of this program, the U.S. Government requires that all Exchange Visitors have a certain level of insurance in effect
which covers the Exchange Visitor during the program dates outlined on the DS-2019 form. AHA purchases insurance through a provider
who meets these requirements.
52. I understand the program fees paid to AHA include insurance coverage for the dates of the DS2019 form only. I am responsible for
purchasing additional insurance to cover dates in the U.S. before and after my program, to include the grace period through my own
insurance provider or I may select to purchase insurance through International Student Insurance I understand I should always call the
insurance provider before seeking medical attention to be pre-approved for procedures whenever possible. Failure to be pre-approved
could result in liability for unwanted medical expenses.

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 53. I understand I am responsible for all medical bills incurred during the program. Furthermore, I agree AHA is not responsible for any bills I
may incur.
54. I understand that the J-1 insurance provided is intended for emergency and urgent medical situations only, it does not cover any bills
associated with pre-existing conditions. I agree to declare all pre-existing conditions to AHA and have additional insurance to cover any
pre-existing condition.

SECTION 6: SEVIS and Embassy

55. SEVIS is the Student and Exchange Visitor Information System, a computerized system that manages data about international students and
exchange visitors in the U.S. Before applying for the J-1 Visa at the Embassy/Consulate, Exchange Visitors must pay the nonrefundable
SEVIS fee. Dependents are not required to pay a SEVIS fee. To learn more about SEVIS go to: https://www.ice.gov/sevis/i901
56. https://exchanges.state.gov/non-us Provide details on travel to and entry into the United States (e.g., procedures to be followed by
exchange visitors and accompanying spouses and dependents in paying SEVIS fees and obtaining visas for entry to the United States,
including the information and documentation needed for the interview; travel arrangements to the United States, and what to expect at
the port of entry, including the necessity of having and presenting travel documents at the port of entry) and the home-country physical
presence requirement.

SECTION 7: Exchange Visitor Responsibilities after Program

57. I agree I will return home at the conclusion of the program to continue studies and/or to pursue a career.
58. I agrees I will not attempt to change visa status while in the United States. I understand that any future visa applications must be initiated
from my home country and that AHA does not support change of visa status.

SECTION 8: Contractual Terms and Other Program-Related Conditions

59. I waive and release all claims against AHA and its employees/agents for any injury, loss, damage, accident, expense or delay caused by or
related to any means of transportation, lodging (hotel, host family, apartment, dormitory, hostel, or pension), school premises,
restaurant, securing passport and visas, or any other services rendered in connection with the program.
60. I release AHA and its employees/agents with regard to any financial obligation to liabilities that the participant may incur or any damage
or injury to the personal property of others that the participant may cause while enrolled in the program.
61. I understand that I am traveling under my own responsibility and hereby release AHA and its employees/agents from any liability related
to health or safety.
62. I understand that I have been advised not to purchase travel tickets until my visa has been issued. If a participant purchases travel tickets
early, AHA is not responsible for any fees incurred by the participant.
63. I agree AHA and its affiliates and partners decline any legal responsibility for: (1) incurred health problems or any personal misconduct or
inappropriate behavior by the participant; (2) Participants expelled from the program; (3) any force majeure (earthquake, floods, strikes,
state of emergency, pandemic, acts of war, etc.).
64. I acknowledge I am responsible for acts along with any resulting loss or damage while on the program. I assume and agree to hold
harmless, indemnify, protect and defend American Hospitality Academy/AHA its officers, employees, agents, host employers, third
parties or others against any and all liability for injuries and damages to AHA its officers, employees, agents, host employers, third parties
or others from any and all liabilities, actions, claims, damage, demands, judgments, losses, and expenses, whether direct or indirect,
including attorney’s fees, arising from any accident, occurrence, injuries, including death, resulting from my negligent or other act(s).
65. I acknowledge AHA makes no representation or warranty of any kind, expressed or implied, as to the suitability of the program for the
Exchange Visitor, and AHA disclaims all such warranties to the full extent of the law.
66. Release. I acknowledge AHA does not own or operate any entity which provides goods or services for the program, including but not
limited to arrangements for or owner-ship or control over houses, apartments, or other lodging facilities; airline, vessel, bus, or other
transportation companies; food service; or entertainment providers. All such persons and entities are independent contractors and enter
legal relationships directly with the Exchange Visitor (and not through AHA). As a result, AHA is not liable for any act or failure to act of
any such person or entity, or of any third party. Without limitation, AHA is not responsible for any injury, loss, or damage to person or
property, death, delay or inconvenience in connection with the provision of any goods or services occasioned by or resulting from, but
not limited to, acts of God, force majeure, acts of war or civil unrest, insurrection or revolt, strikes or other labor activities, criminal or
terrorist activities or the threat thereof of any kind, overbooking or downgrading of accommodations, structural or other defective
conditions in houses, apartments or other lodging facilities (or in any heating, plumbing, electrical or structural problem therein),
mechanical or other failure of airplanes or other means of transportation or for any failure of any transportation mechanism to arrive or
depart timely, dangers associated with domestic or wild animals, sanitation problems, food poisoning disease, epidemics or the threat

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 thereof, lack of, access to or quality of medical care, difficulty in evacuation in case of medical or other emergency, or for any other cause
beyond the direct control of AHA.
67. Indemnification Clause: I agree to indemnify and hold AHA harmless from all claims and damages related to actions brought against AHA
for injury or damage caused by Participant and to reimburse AHA for any expenses incurred for such claims brought against AHA while
Participant is enrolled in the Program, present at a AHA location or while using AHA facilities, services, and/or equipment, as well as for
costs and expenses based upon receipt of medical care or treatment for any physical or mental condition, etc., including, without
limitation, claims which arise from Participant’s negligence, horseplay, violation of any AHA rule, willful misconduct, or criminal behavior.
I agree to accept responsibility if Participant’s acts or omissions cause or threaten to cause damage of any kind whatsoever to Third
Parties. Further, in the event of such damage or loss, I agree to indemnify and hold AHA harmless from any and all liability or actions
taken by Third Parties for said damage or loss.
68. Foreign Travel and Assumption of Risk Travel in nations where AHA operates programs may not be similar to travel within the
Participant’s home country. Programs in nations where AHA operates can involve inconvenience and risk, including, but not limited to,
forces of nature, geographic, and climatic conditions, different hygienic standards, infrastructure problems (such as road maintenance,
transportation delays, and accommodation conditions), civil unrest, vandalism, crime, political instability, and terrorism. Medical services
or facilities may not be readily available during all or part of the Program and, if available, may not be equal to standards in the
Participant’s home country. Participant may be exposed, or expose others, to contagious and potentially harmful or deadly diseases
including, but not limited to influenza, common cold, meningitis, or measles. Participant may also be exposed to risks while traveling
(including but not limited to, buses, trains, private cars, taxis, airplanes, and bicycles), exposure to large crowds (including, but not limited
to, museums, festivals, musical events, sporting events, etc.), and exposure to risks related to receipt of treatment for any physical or
mental condition. Participant assumes all risk of bodily injury, death, emotional trauma, property damage, inconvenience, and/or loss
resulting from such risks.
69. Demonstrations, Rallies and Protests and the like are reasonably frequent in many countries. Any observation, attendance or
participation is solely at Participant’s own risk. I agree to hold AHA harmless from any liability as a result of Participant’s attendance at or
near or participation in any such event.
70. I agree that AHA is not my employer, AHA is not an employment agency. I understand and agree AHA is a cultural exchange organization
and the Sponsor my J-1 visa. If a court, government agency or legal authority finds that AHA has a duty under foreign or U.S. federal,
state or local law, I understand and agree that AHA’s liability (if any) shall be no greater than its role as a an educational and cultural
exchange sponsor and be limited to the fees collected by AHA for these services. I agree that nothing herein described in this paragraph
or in the Agreement creates a duty or obligation under the law, and that the language written herein is provided solely for the purpose of
limiting liability to AHA’s role as sponsor. I further agree that AHA’s liability is subject to the limitations set forth in separate paragraphs
described within.
71. I agree that AHA and/or its officers, employees, independent contractors and agents are neither responsible nor liable for any
events beyond their control, including, without limitation, Government restrictions that may interfere with or preclude operation of
the Program; any events directly or indirectly caused by any intentional or negligent acts or omissions by the Host Employer or those
with whom Participant comes into contact as a consequence of participating in the Program; the necessity of the Participant
returning to the Participant’s home country early or ending the Program early due to health reasons, transportation (e.g., air travel);
terrorism; wars; and natural disasters.
72. If I wish to lodge a complaint about any services provided by AHA I will first immediately inform AHA in writing in order to first give AHA
the chance to rectify the problem. In the event I cannot obtain satisfactory resolution to the problem, I agree to submit the complaint in
writing within 30 days after the end of the Program. No complaint will be considered unless the above procedure is followed.
73. I agree that any dispute concerning, relating, or referring to the SWT Host Employment Offer, the Program Application, any other
literature concerning the program, or the program itself shall be resolved exclusively by binding arbitration in Monroe County, Florida,
per the existing commercial rules of the American Arbitration Association. Such proceedings will be governed by Florida law. The
arbitrator and not any federal, state, or local court or agency shall have exclusive authority to resolve any dispute relating to the
interpretation, applicability, enforceability, conscionability, or formation of this contract, including but not limited to any claim that all or
any part of this contract is void or voidable.
74. Cost of Arbitration. In the event of arbitration, I understand and agree that the non-prevailing party must reimburse the prevailing party
for all reasonable attorneys’ fees and costs resulting therefrom.
75. Cost of Litigation. In the event that a court or legal authority fails to enforce the arbitration clause set within, I understand and agree that
the non-prevailing party shall reimburse the prevailing party for all reasonable attorneys’ fees and costs resulting from the cost of the
litigation, including, but not limited to any trial and/or appeals.

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SECTION 9: WORK AND TRAVEL PROGRAM FEE CONFIRMATION AND DISCLOSURE
76. The following confirms you have been provided an itemized list of all fees paid to AHA and/or a third party to participate in
the Program. Participant understands I understand the program fees paid to AHA include insurance coverage for the dates of the
DS2019 form only. I am responsible for purchasing additional insurance to cover dates in the U.S. before and after my program, to
include the grace period through my own insurance provider or I may select to purchase insurance through International Student
Insurance

FEE TITLE WHAT IT INCLUDES AMOUNT IN USD

Sponsor, Agent Fee and Required Insurance for Dates on DS 2019
1390
Program Fee and Insurance Form $
Embassy Fee If included in program fee enter $0.0 $ 185
SEVIS If included in program fee enter $0.0 $ 35
Airfare to USA If total amount not available, enter estimate $ 700-1200
If no other, enter $0.0
Registration fee 20
Other (must enter description) Description:_______________________________ $
Refund in Event of Visa Denial Amount Participant will receive if visa is denied at Embassy $ 840

SECTION 10: REFUND POLICY

77. Cancellation after documents received and moved To Be Placed: If an application is withdrawn/canceled from the program
due to any reason after candidates file moved To Be Placed, AHA will retain $200. GRP will retain $ 350
______________ for a total
550
of $_______________.
78. Cancellation after issuance/generation of the Draft DS-2019. NO REFUND
79. Embassy/Consulate Denial. In case of a visa denial at the US Embassy, Participant must inform AHA within 5 business days of
denial and return the original DS-2019 Form and original proof of denial from the Embassy or Consulate within 30 business
190
days from the date of denial to receive refunds. AHA will retain $360. GRP will retain $______________ for a total of
550
$ ____________.
80. NO REFUND/NO CREDIT If, once in the United States, Participant program is ended/canceled due to any reason to include
but not limited to: personal choice, host ending the program (laid off, termination), an official decision of the local
government, American government, no refund is issued regardless of the length of time remaining for the scheduled
program.
81. AHA recommends participants to research and consider Trip Interruption Insurance as there is no exception to the refund
policy

SECTION 11 MISCELLANEOUS FEES

The miscellaneous fees will be paid only if/when the following specific circumstances arise:

• Travel Insurance Elective Enrollment: $110

• Second SWT Job, includes Vetting New Host: $25
• Change of Host: $100
• Reissue of DS-2019 shipped outside U.S.: $200
• Reissue of DS-2019 due to I-515A: $100
• Reprint of Lost/Damaged DS-2019 while in U.S.: $25 (priority expediate mailing paid by EV).

* Insurance fees or government fees are subject to change. Insurance rates are reviewed each July for September effective date. Government fees
(SEVIS/Embassy) can change without notice.

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SECTION 12: FINANCIAL SECURITY STATEMENT
82. Per regulations, applicants must be able to support themselves during their entire stay in the US (duration of program plus travel dates)
to be eligible for the J-1 visa. The suggested minimum amount is $2,000 USD. Please check the statement below that applies to you:

I confirm I have adequate financial resources (as outlined above) to support myself during my program. I understand
my program wages may not cover all my expenses. I understand I am required to purchase a round trip ticket. In the event
it is not possible to purchase a round trip airline ticket, I confirm in the event my program ends early, I will have the funds
available at any given time to purchase a return airline ticket and repatriate to my home country.
AND/OR

I have a guarantor/parent/guardian who will support me during my program (as outlined above). Furthermore, I
understand I am required to purchase a round trip or open-ended return flight airline ticket to my home country. In the
event it is not possible to purchase a round trip airline ticket, my guarantor/parent/guardian confirms if my program ends
early for any reason, he/she will purchase a return airline ticket so I may repatriate to my home country.

Signature: ______________________________________________________________________________

Guarantor/Parent/Guardian Information and Statement:

Luis Alfredo Colonio Garcia Father
Name:_________________________________ Relationship to Applicant: __________________________

[email protected]
Email: _________________________________ Telephone: ______________________________________
996271041

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SECTION 13: SIGNATURE Agreement and Acceptance
By typing my name below, I acknowledge that I have read and understood all sections of this document and
agree to abide by its terms, conditions, contents and instructions. I understand that failure to comply with any
of the rules, regulations of the program could result in the early termination of my program at AHA’s
discretion. I, the undersigned, confirm that I have read, fully understand, accept and agree to be bound by all
of terms and conditions set forth in this Agreement and that the information I have provided is true, accurate
and complete.

By typing my name below, I am signing this Agreement electronically and agree my electronic signature is the
legal equivalent of your manual signature on this Agreement.

Lisset Cristina Colonio Soto 62001

Print Participant Name:_______________________________________ AHA ID#:_________________________

10/04/2023
Signature:__________________________________________________ Date:_____________________________

Emergency Contact Information: Parent/Guardian Information

Luis Alfredo Colonio Garcia Father

Emergency Contact Name:_____________________________________ Relationship:______________________
996271041 [email protected]
Emergency Telephone Number:______________________________ Email:____________________________________

GO WEX PERU GIANCARLO TOCTO

GRP Company Name:___________________________ Rep Name (Print):________________________________

GRP/Country Representative Signature. By signing below I confirm the information provided within is correct and has
been fully disclosed and explained to my exchange visitor candidate.
10/03/2023
Signature: _______________________________________________ Date: ______________________________

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 Travel Supplementary Insurance Coverage
Travel Cancellation, Travel Delay, Travel Interruption

AHA J-1 Cultural Exchange Participants are eligible to purchase Travel Supplemental Insurance Coverage, hereafter
referred to “Travel Insurance” that will assist in covering expenses paid in association with their Intern/Training/SWT
programs due to any of the following:

• Travel/Trip Cancellation
• Travel/Trip Delay
• Travel/Trip Interruption.

FREQUENTLY ASKED QUESTIONS:

What is the cost?

$110.00

When is payment due?

At the same time as program fees

What are the policy dates?

Participants must notify AHA of their visa approval, your policy will go effective the date you notify AHA of your visa
approval.

What happens if my visa is denied?

Since visa denial is not covered under this policy, AHA does not purchase the policy for you until after visa is approved as
outlined above. Therefore, if your visa is denied, AHA will reimburse $100.00.

Is this insurance optional?

AHA believes Travel Insurance is important to protect your investment to participate in the program. As outlined in the
AHA agreement, once your visa documents have been issued, AHA program fees are non-refundable. This policy helps
to insure up to $4500 of your costs associated to participate in the program in event your program is cancelled, delayed,
or interrupted (as described below). Anyone who elects not to purchase the insurance will be required to sign a waiver
and release and fully understands fees are non-refundable.

If the program is cancelled due to the reason indicated in the policy where can the insurer file, the claims? Will AHA
assist the participants?
The participant must file the claim directly with the insurance company, AHA cannot file the claim on the participant
behalf (this is not permitted). However, AHA will assist by providing the participant with a receipt of fees paid to AHA to
participate in the program. Participants must keep records of other costs including airline tickets.

If the employer ends my program for cause (terminated), will my fees be covered?
No. Policy only covers if the employer lay off, ends, or shortens the program for any reason other than terminated for
cause. If your program is terminated FOR CAUSE from Host Employer and/or AHA, for example, violation of host
employer rules, termination from employer under progressive discipline policy or act of gross misconduct. Violation of
AHA policy, rules and/or J-1 visa regulations, you will not be entitled to any benefits from the Travel Insurance policy.

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INSURANCE OVERVIEW

Please note, this is an overview, for full details please review the Leisure Travel Policy (“Policy”) with Group Policy
Number: LTG273750; located in the library. The “Policy” supersedes this document.

At the time of paying program fees, participants may choose to purchase the Travel Insurance. The cost of this insurance
is $100.00 and will provide insurance coverage that will provide benefits for cancellation of participants program prior to
arrival to the United States and interruption of participants program during their time in the United State for covered
reasons as described within. This fee is not part of the program fee and is charged in addition to all other fees.

The maximum amount payable to the participants under this policy is $4500.00. Coverable expenses include Fees paid
to participants home country agency, fees paid to U.S. visa sponsor, airline fees and expenses related to possible
quarantine – up to a maximum payout of $4500.00. This policy will NOT cover fees associated with a visa denial, SEVIS
fees or any fees paid to the U.S. Government. In addition, this policy will not reimburse any fees participants paid for
participation in this program should there be any border closures.

This insurance policy is not mandatory, however if participants decide not to purchase this policy, AHA will not issue any
refunds of paid program fees should the participant withdraw from their program or if their program is cancelled due to
any of the causes covered under this policy as stated below. Please review AHA’s Refund Policy as outlined in the
agreement for full details.

DESCRIPTION OF COVERAGE:

Program/Travel Cancellation:

If your travel is cancelled outright and deemed as covered under the policy by the Insurance Company Insurance
Company will reimburse you up to a maximum of $4500.00 if you are prevented from traveling for any of the following
covered reasons that take place after the Effective Date: Sickness, Accidental Injury, or death; Being quarantined*,
required to serve on a jury, subpoenaed; Natural Disaster; Terrorist Attack; Strike; Breakdown of Common Carrier.
*Quarantine coverage is limited up to 14 days maximum and $150.00 per day maximum for food, lodging and
transportation.

Example: If you have purchased your airline ticket to come to the U.S. and have paid your program fees, and you are
unable to come to the U.S. for any of the above stated reasons, the insurance company will reimburse fees you have
paid toward your plane ticket and program fees up to $4500.00. (NOTE: Visa denials and border closures are not a
covered expense).

Trip Delay:

Insurance Company will reimburse You up to $4500.00 for Covered Expenses on a one-time basis if You are delayed in
route to or from Your Travel for twelve (12) or more hours. You must be a ticketed passenger on a Common Carrier.

Covered Expenses include charges incurred for reasonable, additional accommodations and traveling expenses until
travel becomes possible. Incurred expenses must be accompanied by receipts.

This benefit is payable only for one delay of the Insured’s Travel. Travel Delay must be caused by one of the following
reasons: (a) Injury, Sickness or death of the Insured Person; (b) carrier delay; (c) lost or stolen passport, travel

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documents or money; (d) Natural Disaster; (e) the Insured being delayed by a traffic accident while in route to a
departure; (f) hijacking; 14 (g) unpublished or unannounced strike; (h) civil disorder or commotion; (i) riot; (j) inclement
weather which prohibits Common Carrier departure; (k) a Common Carrier strike or other job action; (l) equipment
failure of a Common Carrier; or (m) the loss of the Insured's and/or traveling companion's travel documents, tickets or
money due to theft.

The Insured’s Duties in the Event of Loss: The Insured must provide the insurance company with proof of the Travel
Delay such as a letter from the airline, / newspaper clipping/ weather report/ police report or the like and proof of the
expenses claimed as a result of Trip Delay

Program/Travel Interruption:

Insurance Company will reimburse You up to a maximum of $4500.00 if your program is interrupted and you must
return to your home country due to one of the following events that take place after the Effective Date and while you
are active in your program: sickness, accidental Injury or death; being quarantined*, natural disaster; terrorist attack;
strike; or theft of passports, visas or event passes that has been reported to the local authorities, program cancellation
by Host Organization. *Quarantine coverage is limited up to 14 days maximum and $150.00 per day maximum for food,
lodging and transportation.

Example: If you are in the U.S. and your program is interrupted and you are required to return home for any of the
above stated reasons causing you to lose time on your program, the insurance company will reimburse you up to
$4500.00 of fees you have paid toward your program and airline fees. Program fee reimbursement will be based on a
pro-rata basis (For Example: if you are ½ way through your program and you must return to your home country due to
any of the above-mentioned reasons, the insurance company will only reimburse you for the time remaining on your
program that you lost). Combined maximum payment up to $4500.00.

POLICY EXCLUSIONS:

Under this policy, you will not be reimbursed for any of the following:

• Program Terminated FOR CAUSE from Host Employer and/or AHA. For example, violation of host employer
rules, termination from employer under progressive discipline policy or act of gross misconduct. Violation of
AHA policy, rules and/or J-1 visa regulations.
• Suicide, attempted suicide, or any intentionally self-inflicted injuries while sane or insane.
• War, invasion, acts of foreign enemies, hostilities between nations (whether declared or not), civil war.
• Participation in any military maneuver or training exercise. Any loss starting while You are in the service of the
armed forces of any country. Orders to active military service for training purposes of two (2) months or less will
not constitute service in the forces. Upon notice to insurance company of entering the armed forces, insurance
company will return to you on a pro-rata basis for any premium paid, less any benefits paid, for any period
during which You are in such service.
• Piloting or learning to pilot or acting as a member of the crew of any aircraft.
• Mental or nervous disorders, unless hospitalized.
• Participation as a professional in athletics. Semi-professional sports.

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 • Being under the influence of drugs or intoxicants, unless prescribed by a Physician. Physician cannot be a family
member.
• Pregnancy and/or Childbirth.
• Commission or the attempt to commit a criminal act.
• Participating in skydiving; hang gliding; parachuting except parasailing; mountaineering; any race; bungee
jumping; speed contest; (speed contest shall not include any of the regatta races;) scuba diving unless
accompanied by a dive master and not deeper than thirty (30) feet; spelunking or caving; heli-skiing; extreme
skiing.
• Accidental Injury or Sickness when traveling against the advice of a Physician. Physician cannot be a family
member.

In addition, this policy will not reimburse fees should the following occur preventing your participation in the
program:

• Visa is Denial and Border Closures.

Please note, should you have to cancel your program for any of the covered reasons listed above, the following fees
remain non-refundable: SEVIS Fees and Visa Fees paid to the U.S. government.

ACKNOWLEDGE AND SIGNATURE

AHA has provided me the option to purchase Supplementary Insurance Coverage for Trip Cancellation, Trip Delay or Trip
Interruption as described within. I confirm I have reviewed the policy information provided and if I would like to elect
this voluntary coverage, it is my responsibility to contact AHA at [email protected]

I, on behalf of myself and on behalf of my representatives, heirs, and executors, hereby agree to defend, indemnify, and
hold harmless AHA, and their officers, employees, or agents from and against any claims, demands, actions, losses or
causes of action whatsoever arising out of or related to any injury to me or damage to me or my property during my
program.

By signing below, I represent that I have fully read, understood, and agree to the items listed WITHIN.

Lisset Cristina Colonio Soto 62001

Participant Name: ________________________________________ AHA ID#: ___________________________
10/04/2023
Participant Signature: _____________________________________ Date: ______________________________

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