Student Agreement Form for National and International Travel

Explanatory Notes about the Student Agreement Form
for National and International Travel:
The form provides a set of basic, minimal requirements for students accepted
for CSM-sponsored travel that involves an overnight stay. Trip facilitators are
free to add their own additional expectations.
This form was designed based upon the ideas of faculty who have led such
trips, faculty more generally, and by consulting other colleges’ and
universities’ forms, policies, and procedures.
Regarding the language about consumption of alcohol: This form allows the
trip facilitator to determine prior to the trip that there are circumstances
congruent with the trip’s educational purposes for students 21 or older to
consume alcohol (such as at a winery in a country where wine is a major part
of the culture and economy, or at a networking dinner at an academic
conference). Trip facilitators are also free to state in the form that there are
no circumstances congruent with the educational purposes of the trip where
alcohol may be consumed.
Regarding the language about health insurance, CSM student athletes are
required to have health insurance. Other students are not required to have
health insurance. It is possible to purchase affordable health insurance for
short periods of international and national travel. This will be required of
uninsured students who desire to participate in international travel and for
those students whose domestic health insurance policy does not cover
international travel. For national travel, students would indicate that they
possess health insurance, or (if they do not possess insurance) that they are
responsible for their health care costs (if any) incurred during the trip.
Short-term international and national medical insurance coverage can be
obtained through the following websites:
www.globalunderwriters.com (for coverage outside of the United States)
www.temporaryinsurance.com (for coverage within the United States)

College of Saint Mary
Student Agreement Form for National and International Travel
This Agreement is signed and given by the undersigned to the appropriate
Vice President at College of Saint Mary in consideration for the opportunity to
participate in CSM-sponsored travel that involves at least one overnight stay.
Participation in this trip is considered to be both an honor and a
responsibility. I understand that I am representing College of Saint Mary and
my behavior during this experience is a direct reflection upon the College. I
will attend and actively contribute to all parts of this experience, including
participating in all pre-trip and post-trip meetings.
I will act responsibly and professionally during scheduled and free time. I
understand that the College of Saint Mary Student Handbook and Code of
Conduct are in full effect during the entire trip. I will obey all state and U.S
laws, laws of the countries I am visiting, as well as College policies and
regulations. If I am under the age of 21, I agree that I will not consume
alcohol. If 21 or older, I will not provide alcohol to minors. If I am 21 or older
and choose to consume alcohol, I will do so only under circumstances
congruent with the educational purposes of the trip as determined by the
Facilitator(s) prior to the trip. I will be subject to College discipline if my
behavior generates disorder, creates disturbance, damages property, or
presents a danger to myself or others.
I understand that the Facilitator(s) have the authority to send me home at
my own expense for violating this agreement, state laws, or the laws of the
United States. I respect the authority and responsibility of the Facilitator(s)
and will abide by their decisions.
National and International Travel sponsored by College of Saint Mary ends on
the last scheduled day of the trip—upon return to the final destination stated
in the itinerary. I will return with my group unless prior arrangements have
been made and approved by the College. College of Saint Mary is not
responsible for any student electing to remain at a site, or travel to another
destination after the trip.
Safety is a primary concern. I will promote a safe environment and
understand that some aspects of the trip may be changed or canceled to
address safety.
In order to promote communication among group members, I agree to limit
cell phone, computer, and other electronics use to emergencies and to free
time. I will turn my cell phone off during presentations and other scheduled
time.
Health Insurance Section: (please complete either option 1 or 2) 1) I possess
health insurance. My policy is through
_________________________________________ (name of insurance
company) and
my policy number is _________________________________. I understand
that I am responsible for meeting the deductible on my insurance.
OR

2) I do not possess health insurance, and I understand I am responsible for
any health care costs I incur during this trip.
For all students traveling on international trips only:
If international travel insurance for health care is not included in my health
insurance policy, or if I do not possess health insurance, I will purchase
special international health insurance coverage for the period I plan to travel
outside the United States.
I understand that my $__________deposit for the trip is nonrefundable,
even if I am unable to go on the trip as planned. I understand that I owe $
______________ towards the cost of the trip, which I will pay in full by
__________________.
The Facilitator(s) of this trip may add additional expectations here:
By signing below I register my agreement with the statements listed on this
document.
Printed Name (Student)
Signature (Student)
Date
Printed Name of Parent/Guardian (if the student is a dependent)
Signature of Parent/Guardian (if the student is a dependent)
Date

College of Saint Mary Release of All Claims
For and in consideration of being allowed to participate in the (specify
activity) by the College of Saint Mary, I release College of Saint Mary, its
faculty and staff, and its administration from all claims, demands, damages,
actions, and causes of action on account of damage to property, bodily
injuries, or death resulting or to result from (specify activity) occurring on
(date, time location) by reason of (describe risks involved).
The undersigned student further authorizes CSM and its agents to provide
emergency medical care should it be necessary.
It is understood and agreed by the parties to this release that this instrument
is a full and final release of all claims of every nature and kind whatsoever,
and that this instrument releases claims that are known and unknown,
suspected and unsuspected as a result of the activity described above.
I further state that I have carefully read the foregoing release and know its
contents and sign the same as my own free act.
_________________________________________ ____________________
Signature of Student
Date
_________________________________________ ____________________
Signature of Parent/Guardian
Date
(if student is under age 19)
_________________________________________ ____________________
Signature of College Official
Date

College of Saint Mary Emergency Contact Information Form
EMERGENCY CONTACT INFORMATION FOR:
Name:
______________________________________________________
Address:
______________________________________________________
City: _______________ State: ___________ Zip Code: _________
Phone Number: _________________________________
In the event of an emergency during the Travel Seminar, please
attempt to contact these persons in the order listed:
Name:
________________________________________________________
Address: ______________________________________________________
City: _____________________ State: ___________ Zip Code: _________
Phone Number: _________________________________
Relationship: ___________________________________
Name:
________________________________________________________
Address: ______________________________________________________
City: _____________________ State: ___________ Zip Code: _________
Phone Number: _________________________________
Relationship: ___________________________________
Name:
________________________________________________________
Address: ______________________________________________________
City: ________________ State: ___________ Zip Code: _________
Phone Number: _________________________________
Relationship: ___________________________________