Release of Legal Claims, Waiver of Liability, Indemnification, and Hold Harmless Statement
By checking the box below, I agree to release ECFMG, its officers, directors, employees, and the agents of each of them (collectively, "ECFMG"), of and from any and all Claims of any kind I may or could have, now and in the future, against ECFMG, as a condition to establishing a Global Education in Medicine Exchange (“GEMx”) account. For the purpose of this Release, “Claims” means all liabilities, complaints, damages, losses and expenses arising out of or in connection with any act or failure to act by ECFMG in connection with my participation in the GEMx program, including any investigation of my credentials, any investigation or finding of irregular behavior (as defined in the ECFMG Policies and Procedures), or any other related activities involving ECFMG or the GEMx program.

By checking the box below, I also agree to indemnify and hold harmless ECFMG with respect to any and all Claims I may or could have in connection with the GEMx program. I understand that (1) only ECFMG and my medical school may determine whether I qualify for a GEMx account; (2) only my medical school may determine whether I qualify to apply for electives through GEMx; and (3) only a school that offers elective placements through GEMx (a “Host Medical School”) may determine whether I qualify for an elective applied for through GEMx. The decision-making authority of ECFMG, my medical school and the applicable Host Medical School in such determinations is ongoing.

THIS RELEASE WAIVES CERTAIN LEGAL RIGHTS THAT I MAY HAVE RELATING TO MY PARTICIPATION IN GEMx.

  By checking this box, I confirm that I have read, understood, and agree to the Release of Legal Claims, Waiver of Liability, Indemnification, and Hold Harmless Statement as described above.

Release of Information Authorization
By checking the box below, I authorize every person, medical school, university, hospital, governmental agency or other entity to release to ECFMG information about me, including records, diplomas, transcripts, and other documents concerning my identity, citizenship or immigration status, educational, academic or professional history and status, or enrollment.

By checking the box below, I authorize ECFMG to send any information that ECFMG has, or may obtain, relating to me or my request to participate in the GEMx program to any Host Medical School, university, hospital, governmental agency or other person or entity who ECFMG determines has a legitimate interest in such information. The information I authorize ECFMG to transmit includes records, diplomas, transcripts, and other documents concerning my identity, citizenship or immigration status, educational, academic or professional history and status, or enrollment.

For further information regarding ECFMG's data collection and privacy practices, please refer to our privacy policy available on the ECFMG website at www.ecfmg.org/annc/privacy.html.

I also release from any Claims all other medical schools, universities, hospitals, registration and licensing authorities, governmental agencies or other persons or entities providing information about me, as well as their officers, directors, employees and agents, for their acts, communications, reports, records, diplomas, transcripts, statements, documents, recommendations, or disclosures made in good faith.

THIS RELEASE WAIVES CERTAIN LEGAL RIGHTS THAT I MAY HAVE WITH RESPECT TO THE PRIVACY OF MY PERSONAL INFORMATION.

  By checking this box, I confirm that I have read, understood, and agree to the Release of Information Authorization as described above.

  By checking this box, I certify that the information in this request to establish a GEMx account is true and accurate to the best of my knowledge and I certify that I have read, understood, and agree to all of the above statements. I also certify that I have read the ECFMG Policies and Procedures Regarding Irregular Behavior and agree to abide by these policies and procedures. I understand that, as provided in the ECFMG Policies and Procedures Regarding Irregular Behavior, among other things, ECFMG may find that submission of falsified documents to ECFMG through GEMx constitutes irregular behavior, which could result in actions including permanent revocation of or permanent bar to ECFMG Certification, GEMx, and other ECFMG programs, among other things.