Student Travel Information and Insurance Form

Student Travel Information and Insurance Form
Name*

First NameLast Name
GTCC Student ID #*
(Not your Social Security No.)
Phone Number*

Area CodePhone Number
Activity*
Email*
Activity Start Date*

MonthDayYear
Activity End Date*

MonthDayYear
Do you have any known health condition(s) that could affect you during this activity?*
Required Insurance Statement

All students participating in field trip at GTCC are advised to have health insurance. If you possess such insurance, please indicate below.
Policy Number (if you do not have insurance please enter N/A)*
Name of Insurance Company (if you do not have insurance please enter N/A)*
Are you under the age of 18? If yes, a parent wavier will be required*

YesNO
Birth Date

MonthDayYear
Date
Waiver of Liability and Hold-Harmless Agreement for GTCC Approved Travel and Recreational Activities

In consideration of my being allowed the go on a field trip with GTCC I hereby agree to release and hold-harmless the Trustees of Guilford Technical Community College and each of the officers, staff, employees and other representatives of the College from any and all liability, claims and causes of action of any kind that I may have or that may arise out of my participation in the field trip/recreational activity. I also agree to indemnify GTCC for any action that may be asserted against them by reason of my participation.

This Release is binding on me, and my heirs, successors and assigns.

In signing this waiver, I acknowledge that I have read and that I understand the Waiver of Liability and Hold Harmless Agreement.
Signature*

Clear
Today's Date*

MonthDayYear
**This form must be completed before any student is allowed to participate in organized, campus recreation programs.**
Traveler's Agreement
I understand that any travel advance made by GTCC is a loan and that I am personally responsible for all monies so advanced to me. If a travel advance is obtained and the trip to which the advance is made is not taken, I agree to repay the advance immediately. I understand that I have up to 30 days following completion of the trip to repay or substantiate the travel costs incurred by submitting a reimbursement form with required original receipts. I have examined this travel authorization request and agree to the terms and conditions.
Signature*

Clear
Today's Date*

MonthDayYear
Should be Empty:

Student Travel Information and Insurance Form

Traveler's Agreement