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Manual of Policies and Procedures for Student Affairs

Chapter 13. Guidelines For Student Travel and Off-Campus Activities

(Exceeding 25 miles)

The University of Texas at Tyler sponsors numerous off-campus activities involving student travel. The liability risk to the

University for such activities is significant. To effectively manage these activities, the Office of Student Success has

developed the following guidelines. For purposes of this document, the staff adviser, coordinator, director, coach, faculty

member or other paid professional overseeing the off-campus activity shall be identified as the Responsible University

Official (RUO). In this guideline the Chief Student Affairs Officer and the Office of International Programs Executive

Director may refer to those persons or their designees.

hese guidelines apply to all student travel if the activity or event meets all of the following criteria and is undertaken by

one

or more currently enrolled students to reach an activity or event.

1. T

he activity or event is sponsored, organized and funded by UT Tyler.

2. The activity or event is located more than twenty-five (25) miles from UT Tyler.

3. T

he activity or event is either:

1. un

dertaken, using a vehicle owned, leased, or rented by the institution; or

2. attendance at the activity or event is required by a registered student organization and approved in writing

by the Chief Student Affairs Officer.

International Travel:

A Request for Approval of Foreign Travel – Faculty/Staff Sponsored Student International Travel form must be completed

and submitted to the Office of International Programs Executive Director at least 45 days in advance of travel.

Mandatory registration with International SOS is required prior to travel for all faculty, staff and students traveling

internationally on university-sponsored trips. The RUO may refer to the Financial Services webpage at

http://www.uttyler.edu/finserv/travelsos.php for information on how to obtain an International SOS membership card.

Guidelines:

The following guidelines have been extrapolated from The University of Texas System Business Procedures

Memorandum 16-03-02, 16-05-02 and the POLICY ON STUDENT TRAVEL adopted by the Board of Regents of The

University of Texas System, November 8, 2001, and apply to off-campus trips. All RUO’s must be familiar with these

documents.

Responsible University Official

At least one RUO must accompany students on any off-campus activity. RUO’

s are responsible for knowing the University

Code of Conduct and its policies. The consequences of noncompliance must be made clear to participants and the RUO

must take appropriate action when aware that participants are in violation. RUO’s are trained annually regarding this

policy, the sexual harassment policy, ADA guidelines, and the University Code of Conduct. The forms to be completed

referred to in this policy are located after the policy.

1. Pre-Trip Orientation

A pre-trip orientation meeting must be conducted for participants prior to the date of departure. Participants should be

inf

ormed of as much detail about the trip and its circumstances as reasonably possible, including all known risks.

Participants should also be informed of emergency response measures and conduct expectations (Appendix F).

2. Group Travel Authorization Request Form – Appendix A

Domestic travel - complete and submit to the Chief Student Affairs Officer for approval at least two weeks prior to

departure. International travel – complete and submit to the Office of International Programs Executive Director at

least 45 days prior to departure.

If the trip is approved the RUO must complete the following paperwork and maintain a copy of these records

throughout the trip in a manner that ensures immediate access to the information for each participant in case of an

accident or health-related emergency. Copies of the below paperwork should also be left with the on-campus forms

custodian (indicated on Appendix G). Originals of Appendix B and Appendix G must be submitted to the Student

Success Office for Domestic travel at least one week prior to departure or to the Office of International

Programs for International travel at least two weeks prior to departure.

roup Travel Authorization Request Form

– Appendix A (Copy of Approved Form)

Group Travel Trip Information Form – Appendix B

Release and Indemnification Agreement – Adult Student – Appendix C or

Release and Indemnification Agreement – Parental Permission (if a minor student) – Appendix D or

Release and Indemnification Agreement – Adult Non-student (RUO) – Appendix I

Emergency Information Contact Form – Appendix E (Intercollegiate athletes see Appendix H)

Participant Responsibility Form – Appendix F

Domestic and International Travel Activity Checklist and Emergency Crisis Response Plan – Appendix G

4. A copy of Appendix A, Appendix B and Appendix G should be forwarded to the UT Tyler Police Department prior to

departure.

5. Departmental Travel Authorization

Travel

authorization, payment and reimbursement processes required by a department or college are required in

addition to these procedures.

6. Medical Insurance

Students traveling on a University-sponsored overnight trip must have medical insurance. Student health insurance

is available to students through Academic Health Plans at https://www.academichealthplans.com/uttyler/. Special

Event Insurance is available for departments to purchase for uninsured students if necessary but must be purchased

prior to the trip. NOTE: The Athletic Department provides secondary catastrophic athletic injury insurance for all

student-athletes, but not health insurance. Student-athletes must secure their own primary health insurance which

does not exclude athletic activities.

7. Weapons, Drugs, and Alcohol

Use or possession of weapons, alcohol or illegal drugs is forbidden while traveling on a University-sponsored trip.

8. Departmental Equipment

Departmental property must be cared for properly. Participants may be charged a replacement fee for lost or

damaged equipment.

9. Drivers and Travel Using a Vehicle Owned or Leased

All travel subject to this policy must be undertaken in vehicles owned, leased or rented by The University or with

common carriers. No personal vehicles are permitted for use in travel that is subject to this policy. Approval includes

the driver being a University employee, having a valid operator’s license with a Motor Vehicle Record of 2 or less, and

participating in instruction and hands-on training (15-passenger vans only). Drivers of motor vehicles shall comply with

all laws, regulations, and posted signs regarding speed and traffic control, or additional directives stipulated by UT

Tyler or the UT System. If University-owned vehicles are available, they should be used for trips within a 60-mile

radius of UT Tyler. All other trips must be booked through the UT Tyler contracted rental company or a charter bus

company. All forms must be completed and all guidelines followed whether travel is in University-owned vehicles,

rental vehicles, chartered bus, or other common carrier.

10. Vehicle Determination and Passenger Capacity

The distance to the destination and/or the number of participants needing transportation determines the type of

transportation to be used. Each vehicle using University employees as drivers should attempt to have two certified

drivers. However, when a trip exceeds 350 miles one way two certified drivers per vehicle are required. On long trips,

drivers should rotate every three hours*, and no more than eight hours of driving should be completed during any one

day. No more than twelve (12) people plus gear, luggage or other items may be loaded in any one 15-passenger van.

In all other vehicles, the total number of passengers may not exceed the manufacture’s recommended capacity or the

number specified in applicable federal or state law or regulations, whichever is lower. Passengers should be seated

toward the front of the van in recognized seating with gear, luggage and other items distributed evenly in the rear

behind the last seat. On trips where the number of participants and available drivers preclude the use of 15-passenger

vans, a chartered bus or mini-bus should be used. When a trip exceeds 450 miles one way and/or require driving after

11:00 p.m., professional drivers must be contracted.

*There may be occasions when, in the best judgment of the RUO, circumstances such as weather, road

construction, sleep deprivation of drivers, unsafe operation of vehicle by drivers, etc., would make this rotation

unsafe. Such decisions should be documented in writing by the RUO to the Chief Student Affairs Officer after

returning to campus.

11. Seat Belts

Occupants of motor vehicles (except charter buses) must use seat belts or other approved safety restraint devices at

all times when the vehicle is in operation.

12. Liability Insurance

Drivers of all motor vehicles must check to make sure that the vehicle has a current proof of liability insurance card,

State inspection certification, be equipped with all safety devices or equipment required by law or regulation and

comply with all other applicable requirements of federal or State law or regulations before departing from campus.

13. Periodic Maintenance

Each vehicle owned or leased by UT Tyler must be subject to scheduled periodic maintenance by qualified persons

and comply with all applicable requirements of The University of Texas System Business Procurement Memoranda.

14. Emergency Procedures

The RUO must implement the following procedures in the event of an emergency:

For University-owned vehicles:

ccident:

o Noti

fy local authorities @ 911.

o Noti

fy UT Tyler Police @ 903-566-7300 who will notify the Director of Environmental Health & Safety.

o Le

ave a cellular phone number with the dispatcher.

o Ref

er to BPM 16-03-02 for Post-Accident Claims Procedures.

Mechanical Breakdown:

o Noti

fy the dispatcher in the UT Tyler Police Dept. @ 903-566-7300 who will notify the Director of

Environmental Health & Safety.

o Le

ave a cellular phone number for someone to call you back.

o Do n

ot attempt to make repairs, including changing a tire. Wait for the Director of Environmental Health &

Safety or UT Tyler Police to call and confirm roadside assistance to the breakdown location.

For rental vehicles:

cident:

o Noti

fy local authorities @ 911.

o Cal

l the 800 number provided by the rental company.

o Ref

er to BPM 16-03-02 for Post-Accident Claims Procedures

o Noti

fy the UT Tyler Police dispatcher @ 903-566-7300.

o Le

ave a cellular phone number for someone to call you back.

Mechanical Breakdown:

o Cal

l the 800 number provided by the rental company.

o Cal

l UT Tyler Police (903-566-7300) if assistance is needed.

15. Monitoring

hen any incident occurs, i.e. accident, mechanical failure, medical emergency, code of conduct violation, etc., the

RUO must call his/her supervisor as soon as is feasibly possible. The supervisor will notify the Chief Student Affairs

Officer or Office of International Programs Executive Director. A meeting must be called as soon as feasibly possible

after returning from the trip to investigate the incident. For medical emergencies or conduct violations, the Chief

Student Affairs Officer or Office of International Programs Executive Director will contact Environmental Health and

Safety and UT Tyler Police when appropriate.

16. Side Trips/Early and Late Departures

Non-University business side trips, such as a trip for entertainment purposes, must be planned and approved in

advance. Trips to known high-risk areas will not be approved and must not be undertaken. Spontaneous activities,

while on the primary trip, such as going to a local movie or special restaurant, shall be at the discretion of the RUO.

Students traveling on University funded trips must arrive at and depart the site at the same time as the advisers. The

RUO’s immediate supervisor and the Chief Student Affairs Officer or Office of International Programs Executive

Director must approve any exceptions to this policy.

17. Parental Permission Form –

Appendix H (Intercollegiate Athletics Only) This form must be completed by the

student-athlete’s parent or legal guardian and returned to the Director of Athletics prior to the student-athlete’s first

practice.

Revised: 12/16/2019

Appendix A

GROUP/TEAM TRAVEL AUTHORIZATION REQUEST FORM

DOMESTIC travel:

Completed form due in the Office of Student Success two weeks prior to departure.

INTERNATIONAL travel: Completed form due in the Office of International Programs 30 days prior to departure.

RUO: Title:

Department: Supervisor:

Depart Date: Return Date:

RUO Cell Phone Number: RUO Email:

Event Name:

Event Destination:

Purpose of Travel: _____________________________________________________________

Mode of Transportation: Rental Car Van Bus Airline Other: ______________

Provide the number of each type of vehicle

LIST DETAILED ITINERARY BELOW (OR ATTACH)

Date

From

Depart

Time

Arrive

Time

Airline/Flight #

(if applicable)

This section to be completed by Intercollegiate Athletics only: (List Estimated Costs)

Cost Center: Departure Date/Time: Return Date/Time:

Vehicle Rental Type : Cost per trip + Fuel Expense (if known) =

Team Lodging : Room Rate x # days x # rooms =

Per diem per athlete (meals) : x # athletes x # days =

Coach Lodging: Room Rate x # days x # coaches =

Coach Per Diem: x # days x # coaches =

Bus Driver Lodging: Room Rate x # days =

TOTAL ESTIMATED EXPENSES:

------------------------------------------------------------------------------------------------------------

RUO Signature: Date:

Date:

Chief Student Affairs Officer/OIP Exec Director Approval

This form may be routed for signature via Docusign or may be submitted by e-mailing a signed, scanned copy to

studentsuccess@uttyler.edu (domestic) or oip@uttyler.edu (international)

Appendix B

GROUP TRAVEL TRIP INFORMATION FORM

DOMESTIC travel: Completed form due in the Office of Student Success 1 week prior to departure.

INTERNATIONAL travel:

Completed form due in the Office of International Programs 2 weeks prior to depart.

EVENT GROUP NAME: ______________________________________________________________

RUO : _____________________________________________ _____________________________

RUO CELL PHONE: ______________________ RUO EMAIL: ____________________________

DATES OF TRAVEL: _______________________________________________________________

CERTIFIED DRIVERS (IF APPLICABLE):___________________________________________________

HOTEL

OR OTHER ACCOMMODATIONS NAME: ______________________________________

HOTEL OR OTHER ACCOMMODATIONS ADDRESS: ___________________________________________

_______________________________________ PHONE #__________________________________

TRAVEL GROUP MEMBER LIST:

NAME

TITLE

(student, volunteer, RUO, etc)

EMERGENCY CONTACT

RUO

NAME:

PHONE:

NAME:

PHONE:

NAME:

PHONE:

NAME:

PHONE:

NAME:

PHONE:

NAME:

PHONE:

NAME:

PHONE:

NAME:

PHONE:

NAME:

PHONE:

10.

NAME:

PHONE:

11.

NAME:

PHONE:

12.

NAME:

PHONE:

Privacy Statement

With few exceptions, you are entitled on your request to be informed about the information UT Tyler collects about you. Under

Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the information. Under

Section 559.004 of the Texas Government Code, you are entitled to have UT Tyler correct information about you that is held by

us and that is incorrect.

SIGNA

TURE OF RUO: DATE:

___________________________

Complete and attach a supplemental Travel

Group Member List if necessary.

This form may be routed for signature via Docusign or may be submitted by e-mailing a signed, scanned copy to

studentsuccess@uttyler.edu (domestic) or oip@uttyler.edu (international).

Rev. 10/2011

Appendix C

RELEASE AND INDEMNIFICATION AGREEMENT FOR ADULT STUDENTS

STUDENT: (Name and Address)

INSTITUTION:

The University of Texas at Tyler

3900 University Blvd

Tyler, TX 75799 (903) 566-7000

DESCRIPTION OF ACTIVITY OR TRIP:

LOCATION: DATE(s):

I, the above named student, am 18 years of age or older and have voluntarily applied to participate in the above

Activity or Trip. I acknowledge that the nature of the Activity or Trip may expose me to hazards or risks that

may result in my illness, personal injury, or death and I understand and appreciate the nature of such hazards and

risks.

In consideration of my participation in the Activity or Trip, I hereby accept all risk to my health and of my injury

or death that may result from such participation.

I hereby release the above named Institution, its governing board (The University of Texas System Board

of Regents), officers, employees and representatives, in their individual and official capacities, from any

liability to me, my personal representatives, estate, heirs, next of kin, and assigns for any and all claims

and causes of action for loss of or damage to my property and for any and all illness or injury to my

person, including my death, that may result from or occur during my participation in the Activity or Trip,

WHETHER CAUSED BY NEGLIGENCE OF THE INSTITUTION, ITS GOVERNING BOARD,

OFFICERS, EMPLOYEES, OR REPRESENTATIVES, OR OTHERWISE.

I further agree to indemnify and hold harmless the above-named Institution and its governing board (The

University of Texas System Board of Regents), officers, employees, and representatives, in their individual and

official capacities, from liability for the injury or death of any person(s) and damage to property that may result

from my negligent or intentional act or omission while participating in the described Activity or Trip.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF

ALL CLAIMS AND CAUSES OF ACTION FOR MY INJURY OR DEATH OR DAMAGE TO MY

PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITY OR TRIP

AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR

INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY MY

NEGLIGENT OR INTENTIONAL ACT OR OMISSION.

Signature of Student

Date:

Witness

Date:

Rev. 10/2011

Appendix D

RELEASE AND INDEMNIFICATION AGREEMENT FOR MINORS

PARTICIPANT: (Name and Address)

INSTITUTION:

The University of Texas at Tyler

3900 University Blvd.

Tyler, TX 75799 (903) 566-7000

DESCRIPTION OF ACTIVITY OR TRIP:

LOCATION: DATE(s):

I am the Parent/Guardian of the above named Participant who is under 18 years of age and am fully competent to sign

this Agreement. I give permission for Participant to participate in the above-referenced Activity or Trip. I

acknowledge that the nature of the Activity or Trip may expose Participant to hazards or risks that may result in

Participant’s illness, personal injury, or death and I understand and appreciate the nature of such hazards and risks.

In consideration of Participant being permitted to participate in the Activity or Trip, I hereby accept all risk to

Participant’s health and of his/her injury or death that may result from such participation.

I hereby release the above named Institution, its governing board (The University of Texas System Board of

Regents), officers, employees and representatives, in their individual and official capacities, from any liability

to Participant, Participant’s personal representatives, estate, heirs, next of kin, and assigns for any and all

claims and causes of action for loss of or damage to Participant’s property and for any and all illness or injury

to Participant’s person, including his/her death, that may result from or occur during Participant’s

participation in the Activity or Trip, WHETHER CAUSED BY NEGLIGENCE OF THE INSTITUTION, ITS

GOVERNING BOARD, OFFICERS, EMPLOYEES, OR REPRESENTATIVES, OR OTHERWISE.

I further agree to indemnify and hold harmless the above-named Institution and its governing board (The University

of Texas System Board of Regents), officers, employees, and representatives, in their individual and official

capacities, from liability for the injury or death of any person(s) and damage to property that may result from

Participant’s negligent or intentional act or omission while participating in the described Activity or Trip.

I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO BE A RELEASE OF ALL

CLAIMS AND CAUSES OF ACTION FOR PARTICIPANT’S INJURY OR DEATH OR DAMAGE TO

PARTICIPANT’S PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED

ACTIVITY OR TRIP AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY

LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY

PARTICIPANT’S NEGLIGENT OR INTENTIONAL ACT OR OMISSION.

Signature of Parent/Guardian

Date:

Address (if different from Participant’s)

Witness

Date:

Appendix E

EMERGENCY INFORMATION/CONTACT FORM

(Non-athletes complete Appendix E; intercollegiate athletes complete Appendix H)

Student’s Name:

In case of an emergency, please notify:

Name ______________________________________Relationship

Street

City State Zip Code

E-mail address(s):

Home: ( )

Work: ( )

Cell: ( )

HEALTH INSURANCE INFORMATION

Does student carry his/her own policy?

If so, list the insurance carrier and insurance

number:

Insurance Carrier:

Policy Number:

If the student does not carry his/her own policy, is the student covered on parent or legal

guardian’s insurance policy? __________ If so, list the parent or legal guardian’s insurance

carrier and insurance number:

Parent’s or Legal Guardian’s Insurance Carrier:

Parent’s or Legal Guardian’s Insurance Policy Number:

If the student does not carry his/her own policy and is not covered by their parent or legal

guardian’s policy:

Academic Health Plans Special Events insurance purchased by:

Appendix F

PARTICIPANT RESPONSIBILITY FORM

Participant(s) should:

1. Read and carefully consider all materials and/or information provided by the RUO that

relates to safety, health, legal, environmental, political, cultural, and/or religious

conditions in the area where you will be going.

2. Make available to the RUO accurate and complete physical and mental health

information and any other personal data that is necessary in planning for a safe and

healthy trip.

3. Assume responsibility for all the elements necessary for personal preparation for the

program and participate fully in pre-trip orientation.

4. Obtain and maintain appropriate insurance coverage and abide by any conditions

imposed by the carriers.

5. Understand and comply with the terms of participation, University Code of Conduct, and

emergency procedures of the program and obey the law. Remember, use or possession of

weapons, alcohol or illegal drugs is forbidden while traveling on a University-sponsored

trip. International Travelers: be responsible for knowing and obeying the laws of the

host country and policies of host institutions and understand that violations of these laws

or policies may result in disciplinary proceedings.

6. Beware of local conditions and customs that may present health or safety risks when

making daily choices and decisions. Promptly express health or safety concerns to the

RUO.

7. Behave in a manner that is respectful of the rights and well-being of others, and

encourage others to behave in a similar manner.

8. Accept responsibility for your own decisions and actions.

9. Follow the program policies for keeping program staff informed of participant’s

whereabouts and well being.

I understand the requirements and conditions stated herein, and I agree to abide by program and

University regulations.

Privacy Statement

With few exceptions, you are entitled on your request to be informed about the information UT Tyler collects about

you. Under Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review

the information. Under Section 559.004 of the Texas Government Code, you are entitled to have UT Tyler correct

information about you that is held by us and that is incorrect.

______________________________

Printed Name Signature Date

Appendix G

DOMESTIC AND INTERNATIONAL TRAVEL ACTIVITY CHECKLIST

AND EMERGENCY AND CRISIS RESPONSE PLAN

DOMESTIC travel: Completed form due in the Office of Student Success 1 week prior to departure.

INTERNATIONAL travel: Completed form due in the Office of International Programs 2 weeks prior to departure.

RUO: ________________________________________________________________________

Event Name: _____________________________________________________________________

RUO’s Supervisor: ________________________________________________________________

Travel Authorization created in PeopleSoft by: _________________________________________



Pre-Trip Orientation Meeting Date:

Traveler Health and Safety Assessment

Person in charge of travel card/cash advance (if not RUO) __________________________

Proof of Insurance in Motor Vehicle and Inspection Certification Affixed

Vehicle Insurance: phone # of provider: __________________________________________

Forms completed for RUO to take on trip (including all of the following: copy of Approved

Appendix A, Appendix B, Appendix G, completed Appendix C/D or I for every traveler, and

Appendix E and F for every traveler)

On-campus Form Custodian: __________________________________________________

(maintains copies of Appendix A, Appendix B, Appendix G & completed Appendix C/D or I for

every traveler, and Appendix E and F for every traveler)

Appendix A, Appendix B, Appendix G sent to Student Success (domestic) or Office of

International Programs (international) AND Campus Police

 Name, address and phone number of closest hospital or emergency care clinic: __________

________________________________________________________________

 International Travel Only:

 Request for Approval of Foreign Travel form completed by RUO and approved by Dean,

Office of International Programs, Provost and President 45 days prior to departure.

 Mandatory registration with International SOS completed by all travelers.

 International cell phone number: ___________________________________________

______________________________________ __________________________

RUO’s Signature Date

This form may be routed for signature via Docusign or may be submitted by e-mailing a signed, scanned copy to

studentsuccess@uttyler.edu (domestic) or oip@uttyler.edu (international).

09/03/14

Appendix H

PARENTAL PERMISSION FORM

Intercollegiate Athletics Only

As parent or legal guardian of _________________________________, I hereby give my consent for (his/her)

practice and play in intercollegiate athletic events.

I also grant permission for treatment deemed necessary for a condition arising during participation in these

activities, including medical or surgical treatment recommended by a medical doctor. I understand that every

effort will be made to contact me prior to treatment.

I agree to the need for a screening medical examination and certify that the medical history below is accurate to

the best of my knowledge.

Students who participate on intercollegiate athletics teams must have athletic injury insurance coverage before

their participation begins. This coverage may be part of the family’s insurance or purchased separately. If, for

any reason, the family’s policy is dropped, the student may not participate on any UT Tyler intercollegiate

athletics team until proof of insurance is received by the athletic trainer at UT Tyler. The NCAA carries

catastrophic insurance coverage with a $90,000 deductible and UT Tyler carries gap insurance to lower the

deductible to $25,000. Contact UT Tyler Athletic trainer for specific coverage limitations.

_______________________________

Signature of Parent or Legal Guardian

Parent’s (or Legal Guardian’s) Address

Name ______________________________________Relationship________________________

Street ________________________City _________________State_______ Zip _____________

In case of emergency call: Business Phone: ___________________________

Home Phone: _________________ Cell Phone: ______________________

Parent’s Insurance Policy Number:________________Insurance Carrier: __________________

Does parent’s insurance policy cover the student during participation in practice, play and travel for

intercollegiate events? Yes ______ No ______

Does student carry his/her own policy? _______ If so, list the insurance carrier and insurance number:

Insurance Carrier: ____________________________Policy Number:

STATEMENT OF RISK

While benefits derived from intercollegiate athletic participation are great, there are also calculated risks involved in

such competition. Both participants and parents are hereby advised that an element of risk is present that could result

in total paralysis or death in all such participation.

Rev. 10/2011

Appendix I

RELEASE AND INDEMNIFICATION AGREEMENT FOR ADULTS

PARTICIPANT: (Name and Address)

INSTITUTION:

The University of Texas at Tyler

3900 University Blvd.

Tyler, TX 75799 (903) 566-7000

DESCRIPTION OF ACTIVITY OR TRIP:

LOCATION: DATE(s):

I, the above named participant, am 18 years of age or older and have voluntarily applied to participate in the

above Activity or Trip. I acknowledge that the nature of the Activity or Trip may expose me to hazards or risks

that may result in my illness, personal injury, or death and I understand and appreciate the nature of such hazards

and risks.