Individual and Travel Waiver Form

Information about this form and Confidentiality Notice: This form is mandated for all students going on trips. An export of this information will be shared with the trip leader and with the student group's adviser. Please note that this form contains CONFIDENTIAL information and will be handled accordingly. Forms should only be reviewed and maintained by one designated officer of the student organization. This information will be used for information purposes only in the case of an emergency.

Departments: 
Insurance Information
Medical Insurance: Students participating in overnight trips associated with a student organization or administrative office are required to have adequate medical coverage. Please state below the provider and policy number of the insurance plan you will be covered by during the program period. It is the responsibility of the student to have proof of medical insurance on his/her person during the trip.
Emergency Contact Information
Please provide your in case of emergency information. This cannot be a fellow student.
Waiver
As a condition of participation in the trip(s) described above, I agree and acknowledge that my participation in this trip is voluntary and that neither The Trustees of Columbia University in the City of New York (the "University), nor any of its 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(s) (including, but not limited to, any personal injury, death, or property damage), and hereby expressly waive all rights, claims, causes of action, and the like of any nature whatsoever which I or my heirs or legal representatives may have against the University or any of its agents or employees in connection with my participation in such a trip.
By typing in your full name, this will serve as your legal signature.
Date of Parent's Signature
Additional Questions
Our hope is that we can bring as many favorite snack foods for the retreat. Just let the staff know and we'll do what we can!

Community Development

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Call: (212) 854-3612

Fax: (212) 854-9801

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