Fillable Student Travel Request (Alabama A&M University)

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Student Travel Request (Alabama A&M University)

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The Student Travel Request (Alabama A&M University) form is 3 pages long and contains:

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  • 0 check-boxes
  • 65 other fields

Country of origin: US
File type: PDF

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Alabama A&M University
Student Travel Request for Authorization
Part I. Requestor/Sponsor/Organization Information
Name of University Faculty/Staff Member Responsible for Trip: ____________________
Position/Title: ____________________________________________________________
Administrative Unit/Organization: ____________________________________________
Phones: Office _____________Cell ____________ Email__________________________
Part II. Student Information
Please attach a roster with A#, name, address, phone number(s), email address, and
emergency contact information for each participant.
Part III. Travel Information
Reason for Travel: _________________________________________________________
Destination: _____________________________________________________________
Dates of Travel: Departure: _________________________ Return: ________________
Total Number of Participants: _________ Attach list of Names for group activity only
Transportation Arrangements (Check one):
Vehicle: ______ Rental Car _____ Personal Car ____ University-Owned Vehicle ______
Common Carrier _______
Name(s) of Drivers:
______________________________________________________________
Lodging Arrangements (Address and Phone Number Required): ____________________
________________________________________________________________________
Phone: ___________________________________________
Part IV. Required Information/Documents:
_______ List of All Participants/Emergency Contacts (Attached)
_______ Release, Waiver, Indemnification Agreement, Covenant Not To Sue
_______ Student Travel Request for Authorization
_______ Student Authorization for Emergency Medical Treatment
Name of University Employee Not Traveling Available for Contact in the Case of
Emergency:_______________________ Contact Number: ________________________
Part V. Administrative Approval
Sponsor Signature/Title/Date: _______________________________________________
Department Chair Signature/Date: ___________________________________________
Academic Dean Signature/Date:_____________________________________________
Vice President for Student Affairs Signature/Date: ______________________________
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RELEASE, WAIVER, INDEMNITY AGREEMENT,
COVENANT NOT TO SUE
THIS RELEASE, WAIVER, INDEMNITY AGREEMENT, AND COVENANT NOT TO SUE is
executed on the ___ day of ______________________, 20___.
In consideration of my participation in the AAMU Office of ________________________
(the “Event”) and other good and valuable consideration, I hereby agree, release and covenant
as follows:
1. With full knowledge and appreciation of the risks associated with participating in the
Event, I acknowledge that I am voluntarily participating in the Event and that I
VOLUNTARILY, KNOWINGLY AND FREELY ASSUME ALL RISKS ASSOCIATED WITH SUCH
PARTICIPATION, known or unknown, anticipated or unanticipated, including the risk
of negligence by persons or entities involved with the Event.
2. I hereby RELEASE, WAIVE, DISCHARGE, and COVENANT NOT TO SUE the state of
Alabama, AAMU, its Board of Trustees, their successors, affiliates, agents, officers,
directors, employees, representatives, and volunteers (collectively hereinafter, the
“Releasees”), jointly and severally, from and/or for any and all liability to me, or my
agents, heirs, executors, administrators, personal representatives, next of kin,
attorneys, and assigns, FOR ANY AND ALL LOSSES, INJURIES OR DAMAGES, AND ANY
CLAIMS OR DEMANDS THEREFOR, ON ACCOUNT OF, ARISING FROM OR RELEATED TO,
ANY INJURY OR DAMAGE TO MY PERSON, OR PROPERTY, INCLUDING DEATH, whether
caused by or resulting from the negligence of the Releasees or otherwise, while I am
observing or participating in the Event.
3. I expressly agree that the foregoing Release, Waiver, Indemnity Agreement, and
Covenant Not to Sue is intended to be as broad and inclusive as is permitted by the
laws of the State of Alabama-, and that if any portion of it is held invalid, it is agreed
that the balance shall, not withstanding, continue in full legal force and effect.
4. I have read, understand and voluntarily sign the RELEASE, WAIVER, INDEMNITY
AGREEMENT, AND COVENANT NOT TO SUE intending to be bound thereby, and
further acknowledge and agree that no oral representations, warranties, statements
or inducements not contained in this written agreement have been made to me by
any person or entity associated with the Event, including Releasees.
5. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A COVENANT NOT TO SUE,
and have signed of my own free act and deed without coercion.
Signature: ____________________________________________ Date:_____________
Printed Name: _________________________________________
Street Address: (home) _________________________________
City, State, ZIP: (home) _________________________________
Telephone No.: (home) _________________________________
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Alabama A&M University
STUDENT AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
Telephone Number: Day: ________________________ Evening: _______________________________
Name of Nearest Relative (or guardian if student is under 18 years of
age):_________________________
Address: _____________________________________________________________________________
Telephone Number: Day: _________________________ Evening: _____________________________
Physician’s Name: _____________________________________________________________________
Address: _____________________________________________________________________________
Telephone Number: Office: ______________________ Emergency: ____________________________
Dentist’s Name:________________________________________________________________________
Address: _____________________________________________________________________________
Telephone Number: Day: _________________________ Evening: _____________________________
Health Insurance Company:______________________________________________________________
Policy Number:____________________________ Telephone Number: ___________________________
Allergies: _____________________________________________________________________________
Current Medications: ______________________________ Special Health Needs: ___________________
EMERGENCY MEDICAL AUTHORIZATION
I, the undersigned, do herby authorize Alabama A&M University and its agents or representatives to
consent, on my behalf, to any medical/hospital care or treatment (including locations outside of the
United States) to be rendered upon the advice of any licensed physician. I agree to be responsible for all
necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization.
The effective dates of this authorization are ______________ to _____________.
_____________________________________ _______________________________ _____________
Print Name (Student) Signature Date
_____________________________________ _______________________________ _____________
Print Name (Parent/Guardian if under 18 year) Signature Date
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Student Travel Request (Alabama A&M University)

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Completed 24 July 2020

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