Southeastern Louisiana University
Student Off-Campus Visitation
As reminders to faculty and staff who are involved with students traveling off campus
due to University classes, events, or approved programs, the following is a checklist of
information the professional staff person may want to have on each student traveling.
*Faculty and staff traveling with students should keep three sets of this information, one for their use on the
trip, one left on campus with their immediate supervisor, and one for the Dean of Students.
_____ 1. Student’s full name and nickname (if any).
_____ 2. Student’s local address and phone number.
_____ 3. Student’s permanent address and phone number.
_____ 4. Person to contact in an emergency, the relationship of that individual to the
student, and a phone number where they can be reached.
_____ 5. Student’s cell phone.
_____ 6. Student’s health concerns, medications taken, medical conditions, and/or any
_____ 7. Student’s doctor’s name and phone number.
_____ 8. Student’s medical insurance company and policy number.
_____ 9. Student’s class schedule.
_____ 10. Student’s W number or social security number.
_____ 11. Student’s destination and date and time of departure and return.
_____ 12. Phone number of hotel or place where student is staying while off campus (if over
_____ 13. Student’s method of travel; and if it involves driving, student’s driver’s license
and vehicle insurance.
_____ 14. Expected behavior guidelines (i.e., Code of Student Conduct, Alcohol Policy,
applicable state and local laws).
_____ 15. Off-Campus Visitation Form (which can be downloaded from
off_campus_vis_9_23_16_new.pdf ). Form should be filled out in triplicate and
have the required signatures by the appropriate dates.
Student Information
For Off-Campus Trips
ame:________________________________ Nickname: ______________________
Student’s University I.D. (W #): ___________________
Local Address: _________________________________________________________
Permanent Address: _____________________________________________________
Cell Phone Number: __________________
Emergency Contact: _________________ Relationship: _________________
Phone Number: _____________________
Medical Conditions/Health Concerns: _______________________________________
Medications Presently Taking: _____________________________________________
Doctor: ____________________ Phone Number: _______________________
Medical Insurance Company and Policy Number: _____________________________
Destination: _______________________ Phone Number: ______________
Date and Time of Departure: ___________________________
Date and Time of Return: ______________________________
Class Schedule: __________________________________________________________
If Driving is Involved
river’s License: __________________
Vehicle Insurance Company and Policy Number: _____________________________
Dean of Students
Student Union RM 2409, SLU 10346, Hammond, LA 70402 | Phone:(985) 549-3792
Fax: (985) 549-5647 |