The College of Wooster Checklist for Traveling

Transcription

1 The College of Wooster Checklist for Traveling Send Student Organization Travel Itinerary to staff in Lowry Center and Student Activities one (1) week prior to departure. Send Organization Travel Roster to staff in Lowry Center and Student Activities one (1) week prior to departure. If renting vehicles from the school, the Transportation Department with the number of vehicles that are required and names of drivers ten (10) business days before departure, and carbon copy staff in Lowry Center and Student Activities on the . Submit the Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement to staff in Lowry Center and Student Activities at least one (1) week before departure. Submit Emergency Contact/Medical Information form with copy of insurance cards to staff in Lowry Center and Student Activities at least one (1) week before departure.

2 W WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT On behalf of myself, I hereby affirm that by participating in the (name of Program) on (date of Program), at The College of Wooster (hereinafter referred to as College ) that you agree on behalf of yourself to all of the following: 1. ASSUMPTION OF RISK: I, on behalf of myself, ASSUME ALL OF THE RISKS THAT MAY OR CAN ARISE OUT OF PARTICIPATING IN THE (name of Program). 2. INDEMNITY/HOLD HARMLESS: I, the undersigned, on behalf of myself, agree to indemnify, keep, save, and hold The College of Wooster, its Board of Trustees, officers, directors, agents, employees, subcontractors or assignees, harmless for any direct, indirect, special, or consequential damages connected to this activity that may incur as a result of any act or omission by the College from and against any and all liabilities, damages, losses, claims, expenses, demands, suits, fines, or judgments, including attorneys fees, costs, and expenses incidental thereto and to the full extent as allowed by the laws of the State of Ohio. In the event of any such injury (including death), loss, damage or claims therefore, you shall give prompt notice to the College. 3. RELEASE/WAIVER: You, on behalf of yourself, and your heirs, personal representatives and assigns HEREBY RELEASE, WAIVE AND DISCHARGE The College of Wooster from any and all liability associated with participating in the (name of Program) at the College. This waiver and release is intended to include all claims for injuries, accidents, illnesses, or property loss, whether known or unknown or anticipated or unanticipated. 4. INSURANCE: You acknowledge that The College of Wooster does not carry insurance on your behalf. 5. LEGAL RIGHTS: This agreement shall be interpreted under the laws of the State of Ohio. I have read the above terms and understand and agree to the contents hereof, and that I have the right and authority to execute this agreement. This agreement shall be binding on behalf of myself, heirs, administrators, executors and assigns. I am 18 years old or older and am fully competent to sign this agreement, thereby agreeing to its terms. Signature Name (Please Print) Date Signature of Parent/Guardian Name (Please Print) Date Telephone Number Address, if applicable Return to:

3 Emergency Contact/Medical Information Complete this form once per academic year unless there are changes In case of a medical emergency, call Security & Protective Services at (330) IMMEDIATELY and request that they contact the Dean on Call. Name of Participant: Student ID #: Organization: Two People to Contact in Case of Emergency Name Relationship Address City/State Home Phone Work Phone Name Relationship Address City/State Home Phone Work Phone Medical Information Attach a photocopy of proof of insurance Name of Participant as shown on insurance card Insurance Company Name Address of Insurance Company Ins. Co. Phone Subscriber & Relation to You Group number ID number Date of Birth Allergies Serious Medical Conditions, Major Surgeries, Medical History We Should Know About (Use the back of form for additional information) Current Prescriptions, Dosages, and Prescribing Doctor Do you wear contact lenses? Primary Doctor Dentist Name Name Address Address City/State City/State Phone Phone A completed copy of this form for each participant must be left at the Lowry Center and Student Activities Office and one copy should be taken with the group leader. The group leader should also have a copy of each participant s health insurance card. If they only have College insurance, request a copy of the necessary information from the Wellness Center.

4 Student Organization Travel Itinerary Name of Organization: Student Travel Leader/Coordinator: Cell: ( Staff/Faculty Travel Advisor: Cell: ( ) ) Departure Date: Return Date: Time: Anticipated Time: Purpose of Travel: Means of Transportation (e.g., College Rental Vans/Cars, Buses, Personal Cars): Name of Accommodations: Address: City: State: Zip Code: Phone: Local Police Department (where you will be staying) address: Local Police Department (where you will be staying) phone number: Please list other phone number(s) at which your organization can be reached in case of emergency. 27

5 Student Drivers and Verification of CoW Driver Authorization 28

6 Student Organization Travel Roster Attach Travel Roster with Emergency Contacts and submit all forms to the Lowry Center and Student Activities Office one (1) week prior to event. Organization: Date(s) of Travel: Name of Travel Supervisor: Cell Phone Number of Travel Supervisor: ( ) Name CoW ID Number Cell Phone Number Date of Birth 29

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