EXCURSION CONTRACT AND RELEASE FORM (International Field Program IRC-Burundi, June-August 2009) Student Name: TNS ID#: Division: General Studies
Name/Title of Trip Organizer: Mark Johnson, Coordinator IFP IRC Date(s) of Trip: Purpose of Trip: International Field Program with IRC (Burundi)
I hereby release The New School and all trustees, employees, and faculty members, chaperones or other persons connected in any way with The New School from any and all liability which may arise from my participation in the activities of or associated with the excursion identified and described above. In addition, I understand that the University Student Code of Conduct is applicable throughout the course of my trip and I agree to by the terms outlined therein. I have read this contract and release form and agree to comply with it and with all New School University policies and procedures. I understand that violations may result in disciplinary action.
Signature of Student:
Date:
Signature of Parent or Guardian if student is under 18 years of age: Date:
EXCURSION EMERGENCY CONTACT FORM (International Field Program IRC-Burundi, June-August 2009)
1. Student Name: Local Address: Local Telephone: 2. Health Insurance Information: Name of Company: Policy Number: Division: NSU ID#:
3.
In the event of an emergency, will you be able to hear fire alarms or other signals, see written instructions or signs, walk down the stairs to the nearest exit without assistance? Circle one: If NO, please explain: YES NO
4.
Please describe any medical condition or disability you have and indicate any medications you are taking:
5.
In the event of an emergency, please contact: (If you are under 18 years of age, please indicate the name of a parent/guardian). All emergency contacts must reside in the United States. Name: Address: Home Phone: Work Phone: Relationship: Relationship:
A).
B).
Name: Address: Home Phone:
Work Phone: