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. Complete y envíe todos los formularios requeridos, que se incluyen en un solo documento, dentro de una semana de su recepción. El documento contiene el Código de Conducta, el Formulario de Consentimiento Médico, la Encuesta Dietética y los Formularios de Reconocimiento. Lea atentamente cada sección, complete todos los campos obligatorios y proporcione firmas cuando sea necesario. Una vez completado, envíe el documento completo a través del portal Jotform. Tenga en cuenta que su información personal permanecerá segura y confidencial. Sólo se utilizará para los fines descritos en los formularios. Los envíos incompletos o tardíos pueden afectar su participación. Si tiene alguna pregunta o encuentra problemas, comuníquese con su acompañante para obtener ayuda.
Name
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First Name
Last Name
Please indicate your current school or affiliation:
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Please Select
Alliance Gertz-Ressler High School
Alliance Renee and Meyer Luskin Academy High
Berkeley City College
Cañada College
Cerritos College
Citrus College
College of Alameda
Contra Costa College
Diablo Valley College
East Los Angeles Community College
El Camino College
EST (Educating Students Together)
Evergreen College
Irvine Valley College
Laney College
Las Positas College
Los Angele Pierce College
Los Angeles City College
Los Angeles Harbor College
Los Angeles Southwest College
Los Angeles Trade Tech
Los Angeles Valley College
Los Medanos College (HBCU Tour)
Los Medanos College (UC/CSU Tour)
Merritt College
Mission Community College
Moreno Valley
Mt. San Antonio College
Sacramento City College
San Bernardino Valley College
San Jose Community College
Santa Rosa Junior College
SEED LA School
West Los Angeles College
West Valley College
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Date of Birth
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-
Month
-
Day
Year
Date
Intended Major
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Medical Forms and Consent
Health Insurance Company
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Health Insurance Company-Group Number
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Name of Primary Care Physician
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Phone Number of Primary Care Physician
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Does the tour participant have any existing medical conditions? If yes, please explain in the next question.¿El participante del tour tiene alguna condición médica existente? En caso afirmativo, explique en la siguiente pregunta.
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Please Select
Yes
No
Please explain your existing medical conditions. N/A if this does not apply. Por favor explique sus condiciones médicas existentes. N/A si esto no aplica
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Is the tour participant currently using medication? If yes, please list in the next question. ¿El participante del tour está usando medicamentos actualmente? En caso afirmativo, indique en la siguiente pregunta.
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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. Indique sus medicamentos actuales, la dosis y la cantidad de veces al día que debe tomar durante el día.
Note any medication you are allergic to - Tenga en cuenta cualquier medicamento al que sea alérgico
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List any food allergies-Enumere cualquier alergia alimentaria
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Emergency Contact Name and Relationship-Nombre y relación del contacto de emergencia
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Emergency Contact Phone Number-Número de teléfono de contacto de emergencia
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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. Al firmar con su nombre a continuación, acepta que esta información es válida, precisa y verdadera. En caso de accidente o enfermedad doy permiso para recibir atención de emergencia o tratamiento si se considera necesario.
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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 . Entiendo que si tengo COVID-19 estaré aislado en mi propia habitación. Mi acompañante permanecerá con el estudiante mientras esté en el hotelEST se reserva el derecho de traspasar el costo de la habitación o las tarifas adicionales asociadas con el aislamiento de COVID tanto a la escuela como a los estudiantes. Esto incluye pero no se limita a: *Costo adicional de hotel *Tratamiento médico Open in Google Translate•FeedbackGoogle Translate
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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-Entiendo que todos los participantes en el recorrido EST HBCU deben cumplir con lo siguiente: * Todos los participantes deben realizar un examen PCR o rápido de COVID entre 24 y 48 horas antes de la salida y proporcionar prueba de un resultado negativo en el enlace proporcionado antes de la salida. *Algunas universidades pueden exigir el uso de máscaras en el interior; tenga una máscara en su poder en todo momento para cumplir con la política de la escuela.
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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. *El participante acepta comportarse de una manera que represente el código de conducta estudiantil de su escuela.
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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. *El participante acepta que cualquier violación de las reglas establecidas de conducta estudiantil puede resultar en la cancelación del derecho del estudiante a permanecer en el tour.
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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. *El participante acepta no abandonar el recorrido ni el hotel en ningún momento por ningún motivo sin el permiso del acompañante ni invitar a otros estudiantes a unirse al recorrido. Hacerlo hará que el estudiante esté sujeto a medidas disciplinarias por parte del acompañante.
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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. *Los participantes se comprometen a no poseer ni consumir bebidas alcohólicas (incluso si tienen 21 años o más), marihuana o sustancias ilegales durante el recorrido. Hacerlo hará que el participante esté sujeto a medidas disciplinarias por parte del acompañante.
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Please Select
Yes, I agree
*Participants agrees to be responsible for any room charges as a result of damage or smoking in the room. *Los participantes aceptan ser responsables de cualquier cargo de habitación como resultado de daños o fumar en la habitación.
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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 transportation home. *Los participantes aceptan ser responsables de la cancelación de este viaje debido a violaciones del código de conducta estudiantil y del transporte a casa.
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Please Select
Yes, I agree
Code of Conduct
Luggage Agreement
*Student participant agrees to bring carry-on luggage for this trip. *El estudiante participante acepta traer equipaje de mano para este viaje.
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Please Select
Yes, I agree
*Student participant understand the dimensions of the carry-on luggage-No larger than 24” (L) + 16” (W) + 10” (H) *El estudiante participante comprende las dimensiones del equipaje de mano: no más de 24” (L) + 16” (W) + 10” (H)
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Please Select
Yes, I agree
*Student participants are not to transport any alcohol, marijuana, or other illegal substances in their luggage. *Los estudiantes participantes no deben transportar alcohol, marihuana u otras sustancias ilegales en su equipaje.
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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. *El participante acepta pagar cualquier cargo impuesto por el hotel por mantener despiertos a otros huéspedes durante la noche debido a la música alta o el ruido que emana de la habitación del hotel del estudiante o por acceder a Wi-Fi, ordenar películas, videojuegos, fumar cigarrillos y marihuana o hacer llamadas telefónicas de larga distancia.
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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. *El participante acepta revisar cuidadosamente cada habitación de hotel antes de la salida. Los artículos personales como teléfonos celulares, billeteras, etc. que se dejen en una habitación de hotel o en un campus universitario se enviarán a la dirección particular del estudiante a su cargo.
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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) *El estudiante participante se compromete a no invitar a extraños a sus habitaciones de hotel (si NO están en nuestro recorrido, NO podrán venir a su habitación de hotel)
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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. *Los participantes se comprometen a utilizar ropa adecuada en todo momento. Esto incluye evitar artículos como pantalones caídos, catsuits, camisas con abdomen, pantalones cortos, jeans rotos que dejan al descubierto la ropa interior o ropa con referencias al sexo, drogas u otro contenido inapropiado.
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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. *El participante acepta que no usará sombreros ni audífonos durante las presentaciones de admisión y que no usará teléfonos celulares durante los recorridos por el campus.
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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. *Los participantes aceptan llegar a tiempo a todas las actividades programadas, incluidas las salidas de autobuses y los eventos, como se describe en el itinerario del recorrido. Esto incluye respetar los horarios designados a lo largo del día, asegurando que sean siempre puntuales para todas las actividades planificadas.
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Please Select
Yes, I agree
* Participant agrees to provide their own way to the next destination if they miss the bus. * El participante acepta viajar por su cuenta al siguiente destino si pierde el autobús.
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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-Reitere cualquier alergia alimentaria que pueda tener, incluidas, entre otras, alergias a nueces, lácteos, mariscos, gluten u otros ingredientes. Si no hay ninguno, escriba 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. Al firmar con su nombre completo a continuación, acepta que ha leído, comprende y acepta los términos anteriores.
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