Course Description

Eduational Travel Forms

Below is a check sheet and the forms you need to turn in to Dr. Reynolds if you are taking a class related to a trip organized by Dr. Reynolds and offered through College of the Canyons. Please run off all sheets and return to Dr. Reynolds by fax at 661-362-5386 or mail them to Dr. Reynolds at 26455 Rockwell Canyon, Valencia, CA 91355. Thank you!

Educational Travel, College of the Canyons, Check-Off List

Trip Destination: _____________________

Student's Name: _____________________

Dates of Trip: _____________________

Instructor: ______________________

Please return all forms to Brad Reynolds either by fax at 661-362-5386 or mail them to Dr. Reynolds at 26455 Rockwell Canyon, Valencia, CA 91355.

MEDICAL TREATMENT AUTHORIZATION WAIVER, RELEASE AND INDEMNITY AGREEMENT

EMERGENCY CONTACT FORM

STANDARDS OF STUDENT CONDUCT FOR EDUCATIONAL TRAVEL

MEDICAL TREATMENT AUTHORIZATION

(2) COPIES OF YOUR PASSPORT PAGE WITH PICTURE

PROOF OF MEDICAL INSURANCE WHILE ON THE TRIP

STUDENT BIOGRAPHY

STUDENT TRAVELING TO AND FROM DESTINATION INDEPENDENT OF THE GROUP

SANTA CLARITA COMMUNITY COLLEGE DISTRICT FOREIGN TRAVEL MEDICAL TREATMENT AUTHORIZATION WAIVER, RELEASE AND INDEMNITY AGREEMENT ASSUMPTION OF RISK FOR PARTICIPATION IN VOLUNTARY ACTIVITY

Participant Name as it Appears on Passport: (“Traveler”) Description of Trip: (“Trip”) Date(s) of Trip: Passport Number Expiration Date: The undersigned Traveler expressly understands, acknowledges and agrees to the following: 1. That this Trip is voluntary and is not a mandatory part of any Santa Clarita Community College District, (“District”), program. 2. Travel to any foreign country may involve changes in plans, unexpected delays and limited access to some services. 3. Traveler is subject to the laws of the country visited. 4. District cannot be held responsible or accountable for the actions of a foreign government or its representatives. 5. By their very nature, the use of transportation, housing, food and other goods, services or activities in connection with this Trip carries a risk to Traveler of personal injury, property loss or both. 6. The cancellation and refund policy as stated in the Trip package will be followed in the event of cancellation or early termination of this Trip for any reason. In no event will the District assume any responsibility or loss. Traveler hereby saves and holds harmless the District for any and all travel arrangements and liability arising therefrom. 7. Pursuant to California Code of Regulations, Subchapter 5, Section 55450, by participating in this Trip, Travel is deemed by law to have waived any claims against the District for injury, accident, illness or death occurring during or by reason of this Trip. 8. Traveler is expected to follow all applicable Board policies that may apply to the course and Trip and adhere to the Student Code of Conduct. In the event of accident or illness, I do hereby consent to whatever x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services. In the event of accident or illness please notify: Name Phone I, the undersigned Traveler, hereby voluntarily release, discharge, waive and relinquish any and all actions of causes of action for personal injury, bodily injury, property damage or wrongful death occurring to Traveler arising in any way whatsoever as a result of engaging in said Trip or any activities incidental thereto wherever or however the same may occur and for whatever period said activities may continue. Traveler does for him/herself, his/her heirs, executors, administrators and assigns hereby release, waive discharge and relinquish any action or causes of action, aforesaid, which may hereafter arise for him/herself and for his/her estate, and agrees that under no circumstances will he/she or his/her heirs, executors, administrators and assigns prosecute, present any claim for personal injury, bodily injury, property damage or wrongful death against the District or any of its officers, agents, servants, or employees for any of said causes of action, whether the same shall arise by the negligence of any of said persons, or otherwise. I, the undersigned Traveler, hereby acknowledge that I knowingly and voluntarily assume all risk of bodily injury, as stated, and expressly acknowledges my intention, by executing this instrument, to exempt and relieve the District, its officers, agents, and employees, from any liability for personal injury, bodily injury, property damage, financial loss or wrongful death that may arise out of or in any way be connected with this Trip. I have read the foregoing and have voluntarily signed this agreement. I am aware of the potential risks involved in this Trip and I am fully aware of the legal consequences of signing this instrument.

Traveler Signature as it Appears on Passport

Date

STUDENT BIOGRAPHY

The more we know more about you the faster we can all become acquainted and enjoy this adventure as a group. Briefly tell us the following:

Name:

Home College:

Academic interests:

Recreational interests:

Why did you decide to participate in this educational travel trip?

What are your current or future career interests?

Have you ever traveled outside the United States? If you answered “yes”, please list the countries you have visited.

Are you an early or late riser?

Do you like to stay up late or retire early?

Please write one sentence that you feel best describes your personality.

What do you hope to see and do during this trip?

ATTACH ONE OF THE PASSPORT SIZED PHOTOS TO THIS SHEET.

College of the Canyons Emergency Contact Form

26455 Rockwell Canyon Road, Santa Clarita, California 91355 (661) 362-3413

Emergency Contact for: (Your Name)________________________________

Your Phone: __________________________________

Cell Phone: ____________

Address: __________________________________

Zip: ____________

E-mail Address _________________________________

Destination: _____________________

Beginning Date of Trip__________________

End Date of Trip __________________

Emergency Contact #1:

Name: __________________________________

Relationship___________________

Phone: __________________________________

Cell

Phone: _________________

Address: __________________________________

Zip: ____________

E-mail Address _________________________________

Emergency Contact #2

Name: __________________________________

Relationship__________________

Phone: __________________________________

Cell Phone: _________________

Address: __________________________________

Zip: ____________

E-mail Address _________________________________

SANTA CLARITA COMMUNITY COLLEGE DISTRICT COLLEGE OF THE CANYONS STANDARDS OF STUDENT CONDUCT FOR EDUCATIONAL TRAVEL

Students participating in College of the Canyons’ Educational Travel Program are representing the United States, the State of California, and College of the Canyons. Any misconduct on the part of program participants may reflect on the Educational Travel Program as a whole, and may produce undesirable results for all program participants. Abuse of the hospitality of a host community or school on the part of a few may result in the loss of opportunities for many. It is important that all program participants observe and abide by the legal and social norms of the community in which they live. Participants are also subject to College of the Canyons’ Rights and Responsibilities. Honesty, courtesy and respect for the laws of the host country are generally the standards by which Educational Travel participants should live.

Participants in Educational Travel may be subject to dismissal from the program if they violate its rules or otherwise conduct themselves in such a way as to jeopardize or embarrass themselves, their fellow students, or the Educational Travel Program. In most cases, dismissal means that student status will be terminated and students will be sent home at their own expense. Students may be subject to dismissal under certain conditions, including, but not limited to the following situations:

1. Failure to attend class and participate in required program activities, or failure to maintain an acceptable level of academic performance, and misconduct as defined in the Student Handbook, Rights and Responsibilities in the Schedule of Classes.

2. Trade in, consumption of, or other involvement in the use of dangerous or illegal drugs or narcotics, or violation of any local law or ordinance with respect to these substances.

3. Involvement in illegal actions as defined and interpreted by the lawful authorities of the host country.

I have read and I understand the rules for student conduct (sign)_________________________________________

SANTA CLARITA COMMUNITY COLLEGE DISTRICT COLLEGE OF THE CANYONS EDUCATIONAL TRAVEL

STUDENT TRAVELING INDEPENDENTLY TO/FROM DESTINATION

I, the undersigned, will be traveling independently to and from the location where College of the Canyons’ Educational Travel Group wil be touring. I will make my own travel arrangements. I understand that I am responsible for my own needs (food, hotel, tours, etc.) and that I release Santa Clarita Community College District, College of the Canyons from any further liability and/or responsibilities.

_________________________ Student’s Signature

_________________________ Parent’s Signature (if student is under 18 years of age)

_________________________ Date

______________________________ Signature

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