Risk Management Office
Request Form for Field Trip or On/Off Campus Activity
The information requested below is required in order to develop a release form. Return this completed request to Risk
Management at risk@csuchico.edu, fax number 898-4513, or campus zip 130. If applicable, also include a copy of any
information concerning the activity, i.e. flyer, etc., that might be distributed to students. Requests will be processed as quickly
as possible based upon the date of the field trip, but please allow at least five (5) working days for processing. Risk
Management will prepare the release form and e-mail it to the contact person with instructions. If you have questions, please
call Risk Management at 898-6588 or visit the Academic Field Trips page on our website at http://www.csuchico.edu/risk.
Today’s Date:
Contact Person Ext. E-mail
CC (name & email):
Cell Number/Emergency Contact Number of Trip Leader/Instructor:
Activity is Being Organized by:
Campus Department (Name):
Zip:
Name of Instructor/Requester: Ext.:
Dept. Chair or Dean Printed Name: Signature:
-OR-
Student Organization (Name): Zip:
Advisor (Name): Signature:
Activity:
Course Number (if applicable):
Title:
Event Name:
Date(s) of Activity – from: to:
Travel Destination/Area: (i.e. city, county, state, country, campground, etc.)
___________________________________ Activity is Part of an A.S. Program. Yes: No: Name of A.S. Program:
Is any funding being provided by Campus, Foundation, Associated Students, IRA, Other (list all entities):
Transportation details:
(If students are driving private vehicles, the university should take no part in making transportation arrangements. Ensure everyone knows the destination.)
Describe in detail the activity to be undertaken, including identified potential risks and any injuries that might result.
Risk Management will need a roster listing of participants. It can be attached to this request, or sent to Risk
Management prior to the trip.
If outing is overnight, include lodging name, address, and phone number, and attach an itinerary.
Attach additional sheets as needed.
RM/Forms-(December 2016)
