Student Life Programs Travel And Waiver Form For Overnight Programs
Students have the opportunity to participate in overnight programs sponsored by Student Life. Participation in these programs is encouraged though voluntary. All students who participate in any overnight program must complete and submit this travel waiver prior to their participation. This agreement is effective for the academic year in which the form is submitted.

Questions or concerns may be directed to Student Life at studentlife@barnard.edu or 212-854-2096.

Name
Your answer
UNI/Barnard Email
Your answer
Date of Birth
MM
/
DD
/
YYYY
BC ID#
Your answer
Cell Phone
Your answer
Local or Campus Address
Residential Hall & Room Number or Local Address with Zip Code
Your answer
IN CASE OF EMERGENCY, PLEASE CONTACT:
Emergency Contact Name:
Your answer
Emergency Contact Relationship to Student:
Your answer
Emergency Contact Home or Cell Phone Number:
Your answer
Emergency Contact Work Phone Number or Email Address
Your answer
Insurance
Medical Insurance: Students participating in trips are required to have adequate medical coverage. It is the responsibility of the student to have proof of medical insurance on her/his person during the trip.

Insofar as the student has a medical condition, it is the responsibility of said student to have all necessary medications during the trip and to administer the prescribed dosage. The student can alert the organizational advisor of a medical condition as appropriate. Responsibility for medication remains with the student.

I verify that I have appropriate medical insurance and will procure proof of insurance as necessary.
Required
WAIVER
As a condition of participation in this overnight trip, I agree and acknowledge that my participation in the optional off-campus, overnight trip is voluntary and that neither The Trustees of Barnard College, nor the College or any of its directors, officers, agents or employees, shall have responsibility for any loss, injury, or damage incurred or suffered by me in connection with my participation in this trip (including, but not limited to, any personal injury, death, or property damage).

To the extent permitted by law and in consideration for my participation in this overnight trip, I hereby expressly waive all rights, claims, demands, and causes of action, of any nature whatsoever, whether caused by the negligence or carelessness of Barnard College, which I may have against the College or any of its directors, officers, agents or employees in connection with my participation in such a trip or activity. It is my express intent that this Waiver shall forever bind the members of my family and my estate, heirs, administrators, personal representatives and assigns.

Electronic Signature:
Your answer
Date:
Your answer
Permanent Address:
Your answer
Signature of parent or guardian (If under 18 years of age)
Your answer
Date:
Your answer
CONFIDENTIALITY NOTICE
A copy of this form will maintained by Barnard College. Please note that this form contains CONFIDENTIAL information and should be handled accordingly.
IMPORTANT INFORMATION
In case of an Emergency, please first contact local help by dialing 911 or the local authorities. Once everyone is out of immediate threat or danger, please call Student Life directly at 212-854-2096. If it is after hours, make sure you leave a detailed message and call Public Safety at (212)854-3362.
Submit
Never submit passwords through Google Forms.
This form was created inside of gBear. Report Abuse - Terms of Service - Additional Terms