Application form for Visit JPCA Colleagues

1. I acknowledge that the Visiting JPCA colleagues is not directly organized by, or the responsibility of, Japan Primary Care Association (JPCA) and I hereby release, and promise not to sue JPCA its officers, servants, agents and employees, as well as the host institution(s) where the Visit is conducted and their respective officers, directors, and employees (hereinafter referred to as "Releasees") from any and all claims, whatsoever arising out of or relating to any loss, damage or injury, including death, that may be sustained by me, or to any property belonging to me, whether caused by the negligence of JPCA, or otherwise, while participating in the Visit, or while in, on or upon the premises where the Visit is being conducted, while in transit to or from the premises, or in any place or places connected with the Visit.

2. I am fully aware of the risks and hazards connected with being on the premises and visiting JPCA colleagues. I hereby elect to voluntarily participate in the Visit, to enter upon the above named premises and engage in activities knowing that conditions may be hazardous, or may become hazardous or dangerous to me and my property. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death, that may be sustained by me, or any loss or damage to property owned by me, as a result of being a participant in the Visit.

3. I further hereby agree to indemnify and save and hold harmless the Releasees from any loss, liability, damage or costs they may incur due to my participation in the Visit.

4. It is my express intent that this Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a Release, Waiver, Discharge and Covenant Not to Sue the above named Releasees.

5. I acknowledge that it is a requirement to hold adequate travel insurance, together with any other personal insurance, to cover the duration of the Visit, and that details of the policy must be provided to the host institution.

6. I agree to maintain the strict confidentiality of all information I may acquire during the Visit, including but not limited to patient medical records, personal information, and any proprietary or clinical information of the host institution. I shall not disclose, copy, or use such information for any purpose other than the Visit. Furthermore, I agree not to take any photographs or videos of patients or medical records without prior written consent from the host institution. This obligation of confidentiality shall survive the termination of the Visit.

7. Governing Law and Jurisdiction: This Agreement shall be governed by and construed in accordance with the laws of Japan. Any disputes arising out of or in connection with this Agreement or the Visit shall be subject to the exclusive jurisdiction of the Tokyo District Court in the first instance.
   
   

I acknowledge and represent that

1. I have read the foregoing Agreement, understand it, and sign it voluntarily as my own free act and deed;
2. No oral representation, statements or inducements, apart from the foregoing written Agreement, have been made;
3. I execute this Agreement for full, adequate and complete consideration fully intending to be bound by same.
4. I confirm that adequate travel insurance has been obtained to cover the duration of the Visit.