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CCSC and ESC Travel/Retreat Waiver

Please fill out this form completely in order to participate in the Student Councils' Retreat on Friday, September 28 and Saturday, September 29th to Frost Valley YMCA in Claryville, New York.

Confidentiality Notice: A digital copy of this form will be taken with the SDA advisors. Please note that this form contains confidential information and will be handled accordingly. The information contained in this form will be only used for emergencies only.

Waiver: As a condition of participation in this trip described above, I agree and acknowledge that my participation in t his 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 (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 completing the form below and submitting, you agree to the above stated terms.

First Name *

Last Name *

Which council are you a member? *

CCSC

ESC

Position on Council *

Columbia Email Address *

CUID # *

Cell Phone Number *

Permanent Address *

Health Insurance Provider *

Medical Insurance: Students participating in overnight trips associated with a student organization are required to have adequate medical coverage. Please share the provider and policy number of the insurance plan you will be covered by during this period. It is the responsibility of the student to have proof of medical insurance on his/her person during the trip.

Policy # *

I am at least 18 years old by the start of the trip. *

YES

If a student is not 18 by the start of the trip, a hard copy of this form will need to be processed with a parent/guardian signature.

Birthdate *

Year

Month

Day

Emergency Contact Information *

Relationship to Student *

Home Phone Number *

Cell Phone Number *

Allergies (Food, etc. If none, enter none.) *

Dietary Needs (If none, enter none.) *

Please let us know of your dietary needs. If you observe Kosher or Halal dietary laws, please let us know if eating vegetarian meals are ok.

Signature *

By typing in your name, this will serve as an official signature.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

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CCSC and ESC Travel/Retreat Waiver

Please fill out this form completely in order to participate in the Student Councils' Retreat on Friday, September 28 and Saturday, September 29th to Frost Valley YMCA in Claryville, New York.

Student Engagement