Student Activities Clubs
Off-Campus Student Roster
Return to:
Ginny Rizzo
Risk Services Representative
Student Name Gender Emergency Contact Name and Phone #
Destination
Student ID# Date of Birth
A copy of this roster must be attached to all College Vehicle
Reservation requests. E-mail a copy to Ginny Rizzo at
rizzov@palmbeachstate.edu for insurance purposes.
Activity/Trip Title
Club
Departing Campus
Destination
Dates of Travel
Advisor
Vehicle Reservation #
Print Form