EST Travel Acknowledgment Forms
Directions
Please complete and submit all required forms, which are included in a single document, within one week of receipt. The document contains the Code of Conduct, Medical Consent Form, Dietary Survey, and Acknowledgement Forms. Carefully read through each section, fill out all required fields, and provide signatures where necessary. Once completed, submit the entire document via the Jotform portal. Please note that your personal information will remain secure and confidential. It will only be used for the purposes outlined in the forms. Incomplete or late submissions may affect your participation. If you have any questions or encounter issues, contact your chaperone for assistance.
Name
*
First Name
Last Name
Please indicate your current school or affiliation:
*
Please Select
Alliance Luskin Academy High School
Berkeley City College
Cerritos College
Citrus College
College of Alameda
Contra Costa College
Diablo Valley College
El Camino College
Evergreen College
Alliance Gertz-Ressler High School
Irvine Valley College
Jack & Jill of America
Laney College
Las Positas College
Long Beach City College
Los Angeles Pierce College
Los Angeles Harbor College
Los Angeles Trade Tech
Los Medanos College
Merritt College
Mt. San Antonio College
Moreno Valley College
Sacramento City
San Bernardino Valley College
San Jose Community College
West Valley College
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Intended Major
*
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Medical Forms and Consent
Health Insurance Company
*
Health Insurance Company-Group Number
*
Name of Primary Care Physician
*
Phone Number of Primary Care Physician
*
Does the tour participant have any existing medical conditions? If yes, please explain in the next question.
*
Please Select
Yes
No
Please explain your existing medical conditions. N/A if this does not apply.
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Is the tour participant currently using medication? If yes, please list in the next question
*
Please Select
Yes
No
Please list your current medications, the dose, and the number of times a day you have to take during the day.
Note any medication you are allergic to
*
List any food allergies
*
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
By signing your name below you agree this information is valid, accurate and true. In case of an accident or illness I give permission to receive emergency care of treatment if deemed necessary.
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COVID 19
This guidance is intended to support safe travel on the EST Black College tour to and mitigate the spread of COVID-19. Disease management strategies are guided by the principle that a safe trip is critical to student well-being, your experience and personal development.COVID-19 is here to stay, but we have learned methods and gained tools to decrease its impact on our health and well-being. In alignment with the policies of the universities we will be visiting, EST will continue to implement COVID protocols—including COVID-19 tests and personal protective equipment—to support these goals and prevent broad disruption to the HBCU tour experience. The guidance is based on current scientific knowledge and anticipated trends. It is subject to change, as COVID-19 conditions can shift rapidly and our response must remain flexible and responsive to dynamic challenges. If you are experiencing COVID-19 symptoms, it is strongly recommended that participants wear a mask and get tested immediately. If you are experiencing symptoms of an infectious disease, including COVID-19 you are asked to stay home. All participants on the EST HBCU tour must comply with the following: Were a mask in the airport and on the plane. IF you are vaccinated, please keep your proof of vaccination with you All participants are required to take a PCR 48 or Rapid Exam 24-48 hours prior to departure and submit to the link provided to you by ESTSome universities may require masks to be worn indoors. Each tour participant should always have a mask in their possession to comply with the school’s policy.
I understand if a have COVID-19 I will be isolated in my own room. My chaperone will remain with the student while at the hotelEST reserves the right to pass on the cost of the room or additional fees associated with COVID isolation to both the school and the students. This includes but it not limited to: *Additional hotel cost * Medical treatment *Airfare to send the student home if needed
*
Please Select
Yes, I understand
I understand that all participants on the EST HBCU tour must comply with the following: * All participants are required to take a PCR or rapid COVID Exam 24-48 hours prior to departure and provide proof of a negative result to the provided link prior to departure. *Some universities may require masks to be worn indoors, please have a mask in your possession at all times to comply with the school’s policy
*
Please Select
Yes, I understand
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Code of Conduct
Excursion agreement
*Participant agrees to conduct him or herself in a manner that represents their school’s student code of conduct.
*
Please Select
Yes, I agree
*Participant agrees that any violation of the established rules of student conduct may result in cancellation of the student’s right to remain on the tour.
*
Please Select
Yes, I agree
*Participant agrees to not leave the tour or hotel at any time for any reason without chaperone permission or invite other students to join the tour. Doing so will make the student subject to disciplinary action by the chaperone.
*
Please Select
Yes, I agree
*Participants agrees not to possess or consume alcoholic beverages (even if age 21 or over), marijuana, or illegal substances during the tour. Doing so will make the participant subject to disciplinary action by the chaperone.
*
Please Select
Yes, I agree
*Participants agrees to be responsible for any room charges as a result of damage or smoking in the room.
*
Please Select
Yes, I agree
*Participants agrees to be responsible for the cancellation of this trip due to violations of the student code of conduct and a one-way ticket home.
*
Please Select
Yes, I agree
Code of Conduct
Luggage Agreement
*Student participant agrees to bring carry-on luggage for this trip or assume any fees assessed for checked luggage.
*
Please Select
Yes, I agree
*Student participant understand the dimensions of the carry-on luggage-No larger than 24” (L) + 16” (W) + 10” (H)
*
Please Select
Yes, I agree
*Student participant understands they not bring any liquids over 3 oz in their carry-on luggage
*
Please Select
Yes, I agree
*Student participants are not to transport any alcohol, marijuana, or other illegal substances in their luggage.
*
Please Select
Yes, I agree
*Student participants must review and adhere to the Southwest Airlines Baggage Policies
*
Please Select
Yes, I agree
Code of Conduct
Hotel Agreement
*Participant agrees to pay any charge imposed by the hotel for keeping other guests awake at night due to loud music or noise emanating from the student’s hotel room or for accessing Wi-Fi, ordering movies, video games, smoking cigarettes and marijuana or making long distance telephone calls.
*
Please Select
Yes, I agree
*Participant agrees to carefully check each hotel room prior to departure. Personal items such as cell phones, wallets, etc. left behind in a hotel room or on a college campus will be shipped to the student’s home address at their expense.
*
Please Select
Yes, I agree
*Student participant agrees not to invite strangers to their hotel rooms (If they are NOT on our tour , they may NOT come to your hotel room)
*
Please Select
Yes, I agree
Code of Conduct
Attire and Cell Phone Agreement
*Participants agree to wear appropriate clothing at all times. This includes avoiding items such as sagging pants, catsuits, midriff shirts, booty shorts, torn jeans that reveal underwear, or clothing featuring references to sex, drugs, or other inappropriate content.
*
Please Select
Yes, I agree
*Participant agrees that no hats or headphones will be worn during any admissions presentations and to not use cell phones while on campus tours.
*
Please Select
Yes, I agree
Code of Conduct
Punctuality and Timeliness
*Participants agree to be on time for all scheduled activities, including bus departures and events, as outlined in the tour itinerary. This includes adhering to the designated times throughout the day, ensuring they are always punctual for all planned activities
*
Please Select
Yes, I agree
* Participant agrees to provide their own way to the next destination if they miss the bus.
*
Please Select
Yes, I agree
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Dietary Survey
Please reiterate any food allergies you may have, including but not limited to allergies to nuts, dairy, seafood, gluten, or other ingredients. If none, type N/A
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Dietary Requirements, please check all that apply
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Gluten-free
Kosher
No Beef
No Pork
Pescatarian
Vegan
Vegetarian
I have no dietary restrictions
By signing your full name below you agree that you have read, understand, and agree to the above terms.
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