Student Travel Form

Contact Information

StarID (ab1234cd).
**Don't remember your StarID?** Retrieve it at www.nhcc.edu/StarID.

First Name

Last Name

Date of Birth

Email Address

Travel Information

Location

Travel Dates

Emergency Contact Information

First Name

Last Name

Relationship

Phone

AGREEMENT
Please read the below carefully and initial if you understand and agree.

1. North Hennepin Community College Student

I acknowledge that I am serving as a representative of North Hennepin Community College (NHCC) and that I have been chosen to represent NHCC and its interests. I am enrolled in at least one NHCC course this semester. I understand that any action I take will affect people's opinion of my organization and NHCC. In accordance with the established NHCC Student Life Financial Procedures, travel requests must be submitted to Student Life no later than 3 weeks prior to departure date. Please obtain a copy of the Student Life Financial Procedures for detailed information regarding In-State and Out-of-State travel, reimbursements, meal allowances, etc.

I affirm that I understand and agree

Initials

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2. Travel Accommodations/Program Participation

I agree to stay at the designated lodging accommodations afforded by NHCC (if any) and return via any transportation arranged by the College. I will attend and participate in all aspects of the program (i.e. conference, educational training sessions, etc.). I will immediately notify the designated College sponsor should an emergency preclude my ability to attend.

I affirm that I understand and agree

Initials

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3. College Policies

I understand that the rules governing student responsibility and behavior as stated in the NHCC Code of Conduct are in effect for the duration of the program. I am responsible for adhering to established policies, heeding verbal and written announcements, and exhibiting reasonable and acceptable behavior at scheduled events and on excursions.

I affirm that I understand and agree

Initials

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4. Alcohol & Drug

I understand that NHCC prohibits the usage, possession, manufacturing, selling, or otherwise distribution of any alcoholic beverage, illegal drug or any controlled substance while on-campus or while off-campus and involved in a College-sponsored activity, service, project, program, or work situation. The illegal or excessive consumption of drugs, alcohol, and/or misconduct due to drug and/or alcohol consumption will not be tolerated and will result in disciplinary action, including but not limited to dismissal from the program and judiciary proceedings.

I affirm that I understand and agree

Initials

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5. Drugs

I understand that illegal drugs as determined by the laws of the United States and the State of Minnesota in any form are not tolerated. Possession or use of illegal drugs is punishable by fine or imprisonment. Student participants found using or possessing illegal drugs in any form are subject to immediate dismissal from the program

I affirm that I understand and agree

Initials

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6. Health Care and Emergencies

I understand that on rare occasions an emergency may develop which necessitates the administration of medical care or hospitalization. NHCC reserves the right to notify emergency medical services for treatment. I also authorize any official representative(s) of the program to provide any health information as appropriate. It is understood that such treatment shall be solely at my expense and I agree to reimburse NHCC for any expenses which it might suffer on account of said injury or treatment thereof. In the event of serious illness, accident, or emergency, my designated emergency contact(s), as indicated on this document, may be notified. I have given careful consideration to, and assume responsibility for, any pre-existing medical conditions that may be impacted by my participation in this program.

I affirm that I understand and agree

Initials

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7. Conduct and Dismissal:

My participation will be subject to all laws including United States, State of Minnesota, and any locality where I participant might be. I understand that the official representative(s) of NHCC has the right to dismiss me from the program at any time if: a) my conduct is deemed unacceptable or violates established rules of behavior; b) I violate laws, rules and regulations of the United States, the State of Minnesota, or the locality where I might be located; or c) the official representative(s) has reasonable cause to believe that my continued presence in the program constitutes a danger to the health or safety of persons, including myself, or property. I understand that a decision to dismiss from the program will be final; that separation from the program will terminate my status as a program participant; and I will remain responsible for costs incurred on my behalf. I understand that once dismissed I will not be allowed to remain in program facilities nor participate in any program activities.

I affirm that I understand and agree

Initials

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8. Communicating with Advisor or NHCC Campus Representative

Whenever possible a NHCC campus representative will be traveling with me. It is my responsibility to communicate with this person and to comply with their instructions and expectations of me. If there is no NHCC representative traveling with me, I will communicate with my advisor or Student Life prior to my departure.

I affirm that I understand and agree

Initials

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I, the undersigned, affirm that the information disclosed on this travel authorization and information form is true and correct. I also confirm that I understand and agree to the information detailed above.

Signature (Full Legal Name)

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Parent Permission

Participants under 18 years of age must have this release co-signed by a parent or guardian.
By providing Parent contact below your parent will receive an email and be required to sign this waiver of liabiltiy and release of reponsibility.

Parent First Name

Parent Last Name

Parent Email Address

Parent Waiver of Liability

Parent Permission

I affirm that I understand and agree

First Name

Last Name

I affirm under penalty of perjury that I have carefully read and understand each of the above statements, agree to all terms and conditions as stated, and that all of the information I provided on this form is true.

Parent Signature

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RELEASE OF RESPONSIBILITY FOR MINOR STUDENT - TRAVEL

am the lawful parent/guardian/custodian of

a minor child and student at North Hennepin Community College, voluntarily and expressly agree that I will not hold North Hennepin Community College (College) or its employees, servants, or agents liable for any injuries which may occur to

arising out of or connected with the

field trip.

I hereby expressly discharge the College from all claims, demands, injuries, damages, actions or causes of action, from all acts of active or passive negligence on the part of the College, its servants, agents, or employees.

I understand that the College does not carry health, accident, or personal liability insurance. I recognize, therefore, that by utilizing this RELEASE OF RESPONSIBILITY, the College clearly indicates that it is unable and unwilling to undertake the risk of liability for negligence of its employees, servants, or agents associated with the

field trip.
The previously mentioned minor child is not required to participate in the said field trip, rather she/he is doing this voluntarily.

acknowledge reading this form and understand all conditions both written and implied.

Parent Signature

Parent Signature

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MEDICAL INFORMATION

All information provided will be kept confidential and will only be used and provided to Emergency Services in the event of an emergency.

List all prescription drugs which are necessary for you to take on trips or activities and what they are for (if none, write "none"):

Do you have any current or past health concerns you feel we should be made aware of (allergies, asthma, diabetes, epilepsy, broken bones, sprains, dislocations, heart conditions, etc.)?
Please explain (if none, write "none"):

Special Requirements (dietary, mobility, etc.)*:

Signature (Full Legal Name)

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