Fillable TRAVEL REQUEST FORM 1 (TR1) REQUEST FOR APPROVAL (Lone Star College System)

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TRAVEL REQUEST FORM 1 (TR1) REQUEST FOR APPROVAL (Lone Star College System)

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  • 7 check-boxes
  • 273 other fields

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Section VI.D.1. Non-Academic Student Travel Procedures Page 8 of 14
TRAVEL REQUEST FORM 1 (TR1)
REQUEST FOR APPROVAL OF LSC SPONSORED STUDENT TRAVEL
Program Name: ______________________________________________________________________________
Destination: ______________________________________________________________________________
Name(s) of LSC Employee Traveling with Group: _________________________________________________
LSC Employee(s) phone contact: _______ - ________ - _______ or ________ - ________ - _______
Budget Account Number(s) to Charge: ____ - _____ - ____ - ____________ - ______ Amount: $ ___________
____ - _____ - ____ - ____________ - ______ Amount: $ ___________
Explanation and Justification of Trip and Expenses:
Destination: ______________________________________________________________________________
Date of Departure: ______________________________
Date of Return: _____________________________
Activity Attending: _______________________________________________________________________
Number of Persons Attending: _________________________
Type of Transportation (vehicle(s), bus, airline, etc.): ____________________________________________
Hotel Accommodations: ________________________________________ Number of Rooms: __________
Meals (estimated): _________________________________________________________
Registration Fees: _____________ persons @ $_________________ per person.
Miscellaneous expenses (itemize): _____________________________________ $___________________
_____________________________________ $___________________
_____________________________________ $___________________
Advanced Payment Requested? YES NO Amount $__________________
LSC Approved/Authorized Drive? YES NO (Must be listed on LSC Approved Drivers
List)
Requested By: _______________________________________________ ____________________
Signature of LSC Employee Date
Approved By: ________________________________________________ ____________________
Signature of Associate Dean or Dean of Instruction** Date
Approved By: ________________________________________________ ____________________
VP of Administrative Services/LEO (Required for Vehicle Rentals) Date
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Section VI.D.1. Non-Academic Student Travel Procedures Page 9 of 14
TRAVEL REQUEST FORM 2 (TR2)
TRIP PLAN AND TRIP ROSTER
Campus: ______________________________________________________________________________
Program: _____________________________________________________________________________
Destination: ___________________________________________________________________________
Purpose of Trip: ______________________________________________________________________
Departure Date: _________________________
Return Date: _________________________
Point of Departure: _________________________
Point of Return: _________________________
Name of Sponsor/Club/Class: _____________________________________________________________
Mode of Transportation: _______________________________________________________________
Vehicle Description:
Make
Model
Color
Owner
Driver’s License Number
(Attach Photocopy of
License)
Date
Proposed Travel Route and Itinerary
(Include Flight Numbers, if applicable, and attach any detailed
itineraries)
Section VI.D.1. Non-Academic Student Travel Procedures Page 10 of 14
TRAVEL REQUEST FORM 2 Continued (TR2)
LSC EMPLOYEE PARTICIPANTS (Faculty & Staff)
FACULTY AND STAFF
EMERGENCY CONTACT
NAME
EMAIL
PHONE #
NAME
RELATIONSHIP
PHONE #
1
2
3
4
5
6
TRIP PARTICIPANTS:
STUDENTS
EMERGENCY CONTACT
NAME
EMAIL
PHONE #
NAME
RELATIONSHIP
PHONE #
1
2
3
4
5
6
7
8
9
10
11
12
Section VI.D.1. Non-Academic Student Travel Procedures Page 11 of 14
TRAVEL REQUEST FORM 3 (TR3)
RELEASE AND INDEMNIFICATION AGREEMENT
STUDENT: ID:
Name (last name first - please print or type)
Address
City, State, Zip Code
DESCRIPTION OF ACTIVITY OR TRIP: _______________________________________
MODE OF TRANSPORTATION:
LOCATION(S) OF ACTIVITY OR TRIP:
DATE(S) OF ACTIVITY OR TRIP: FROM _____________ 20 TO ____________20 ______________
I, the above named student, am eighteen 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 and I hereby release Lone Star College, its governing board,
officers, employees and representatives from any and all 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 Lone Star College, its governing board,
officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless Lone Star
College and its governing board, officers, employees, and representatives 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 authorize the College to use or show any photos of the event which include me or my likeness.
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.
Date signed:
Signature of Student
Date signed:
Signature of Witness
Printed Name of Witness
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Section VI.D.1. Non-Academic Student Travel Procedures Page 12 of 14
TRAVEL REQUEST FORM 4 (TR4)
STUDENT TRAVEL WAIVER AND HOLD HARMLESS AGREEMENT
Student Name: _________________________ LSC Organization: _____________________
Name of Activity: ___________________________
Location of Activity: _____________________________________
Vehicle Type: ________________________ License Plate Number: ____________________
Auto Insurance Carrier: ________________________
Cell Phone Number: __________________________
Emergency Contact Name: _____________________ Contact Number: _________________
Check One: Driver ______ Passenger ______
I, the above-named Student, am eighteen (18) years of age or older, and am voluntarily
participating in the above Activity. I acknowledge that Lone Star College (“LSC”) has offered to
provide transportation to and from the Activity. However, I have knowingly and voluntarily
determined to not use such transportation, but rather drive my own vehicle or travel in the vehicle
of another student. I understand and acknowledge that serious accidents sometimes occur during
travel such as this, and that that my travel could result in loss of or damage to my property, injury to
myself or to others, and/or death. I am aware of the inherent potential risks associated with such
travel and am willing to assume these risks. I understand and acknowledge that LSC accepts no
responsibility for my travel and that my travel and any injuries or damages resulting therefrom are
not covered by any LSC insurance policies.
In consideration of my participation in the Activity, on behalf of myself, my family, heirs, and
personal representative(s), I hereby release LSC, its governing board, officers, employees, and
representatives (collectively the “Releasees”) from any and all liability for any and all claims and
causes of action for loss or damage to my property, personal injury or death, that may result from or
occur as a result of my travel. I further agree to indemnify and hold harmless the Releasees from
liability arising from my tortious acts or omissions.
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 PROPERTY
THAT OCCURS WHILE TRAVELING TO OR FROM THE ACTIVITY AND IT OBLIGATES ME TO
INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FROM MY TORTIOUS ACTS OR
OMISSIONS.
I further agree that this Release shall be construed in accordance with the laws of the State of
Texas. If any term or provision of this Release shall be held illegal, unenforceable, or in conflict with
any law governing this Release the validity of the remaining portions shall not be affected thereby.
_______________________________________ _____________________
Signature of Participant Date Signed
______________________________________ _____________________
Signature of Witness Date Signed
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Section VI.D.1. Non-Academic Student Travel Procedures Page 13 of 14
TRAVEL FORM 5 (TF5)
INCIDENT REPORT
Student Name: _______________________ ___________________________ __________
Last Name First Name Middle
Address: _______________________________________________________________________
Phone: ______________________________
Student ID: _________________________________
Incident Description:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Incident Location: ___________________________________________________________________________________
Date: ___________________________ Time: ________________________________
Witnesses: _________________________________________________
_________________________________________________
_________________________________________________
First Aid Rendered (if necessary) __________________________________
Ambulance Called: ☐ Yes ☐ No
Transportation: ☐ Ambulance ☐ Self ☐ Other __________________________
Recommended Follow-up with Physician: ☐ Yes ☐ No
____________________________________ ________________________________
Chaperone Name Signature and Date
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Section VI.D.1. Non-Academic Student Travel Procedures Page 14 of 14
[STUDENTS MUST COMPLETE THIS FORM BEFORE MEDICAL AID MAY BE RENDERED]
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
I. MEDICAL INFORMATION (please type or print legibly)
a. Name
(Last, first, middle)
Address
(Street or P.O. Box, City, State, Zip Code)
Telephone Number: Day ( ) Night ( )
b. Name of Nearest Relative
(Last, First, Middle)
Address
(Street or P.O. Box, City, State, Zip Code)
Telephone Number: Day ( ) Night ( )
c. Physician’s Name
Address
(Street or P.O. Box, City, State, Zip Code)
Telephone Number: Office ( ) Emergency ( )
d. Dentist’s Name
Address
(Street or P.O. Box, City, State, Zip Code)
Telephone Number: Office ( ) Emergency ( )
e. Health Insurance Company Name
Policy Number Telephone ( )
f. Allergies
g. Current Medications
h. Special Health Needs
II. EMERGENCY MEDICAL AUTHORIZATION
I, _______________________, do hereby authorize Lone Star College and its agents or representatives to
consent, on my behalf, to any medical/hospital care or treatment (including locations outside the
U.S.) to be rendered upon the advice of any licensed physician. I agree to be responsible for all
necessary charges incurred by any hospitalization or treatment rendered pursuant to this
authorization.
The effective dates of this authorization are to 20 .
I am eighteen years of age or older, have read the above authorization, and confirm that the
information contained therein is true and accurate.
Date 20 .
(Signature of Individual Providing Authorization)
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TRAVEL REQUEST FORM 1 (TR1) REQUEST FOR APPROVAL (Lone Star College System)

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Completed 6 October 2020

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