Cabrillo Community College District
Field Trip/Study Travel Programs
GENERAL RELEASE
____
Semester
Location of Study
Sign and return this copy to BELA office, Room 301.
KNOW ALL PERSONS BY THESE PRESENTS THAT:
WHEREAS Cabrillo Community College District is providing credit for out-of-state studies, and
WHEREAS the undersigned ______________________________________ is a student desiring to secure credit
for out-of-state studies by participating in the _____________________________________ Study Travel Program
of Cabrillo Community College District, and
WHEREAS it is deemed in the best interests of the parties to provide a general release for the Cabrillo Community
District:
NOW, THEREFORE, in consideration of mutual promises and covenants and other good and sufficient
consideration, the undersigned hereby releases the Cabrillo Community College District and its instructors,
teachers, agents, employees, Board members, volunteers and officers from the following:
A.
Any and all claims against the Cabrillo Community College District and its instructors, teachers, agents, employees, Board
members, volunteers and officers for injury, accident, illness, death or property damage occurring during or by reason
of the student’s participation in the Study Travel Program.
This release includes, but is not limited to, any and all claims incurred or arising from any act or omission of any
transportation agency, service, company, firm, or individual, including but not limited to airline, railroad, bus, taxi,
automobile, sight-seeing service, or agency, any hotel, motel or other place of living accommodation, and any and
all claims incurred or arising from weather, illness, quarantine, government rules and regulations or restrictions,
war, riots and/or strikes.
B.
It is further understood and agreed by and between the parties that the undersigned student is responsible for any and all
claims, liabilities, obligations, financial or otherwise incurred by the student during the term of the program, including but not
limited to any and all obligations and/or liabilities incurred by the student where the program is conducted.
C.
It is further understood and agreed by and between the parties that the undersigned student hereby covenants and agrees to
indemnify, defend and hold harmless Cabrillo Community College District and its instructors, teachers, agents, employees,
Board members, volunteers and officers from and against all loss, cost, damage and expense, and claims and demands
therefore, and for reasonable costs and attorney fees that may arise out of any circumstance outlined in Paragraphs A and B
of this agreement, or any act, omission or conduct of the student out of which may arise any claim or civil action or charge of
criminal violation, whether or not the acts, omissions or conduct are those of the student alone or in consort with others.
I have read, understand and hereby agree to the Cabrillo Community College District General Release for Field Trip/Study
Travel Programs:
___________________________________________ ____________________________________________________
Signature of Student
Signature of Parent or Legal Guardian if student under 18 years of
age
__________________
_________________
Date
Date
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Cabrillo Community College District
Field Trip/Study Travel Programs
STANDARDS OF STUDENT CONDUCT
College districts are required by law to adopt standards of student conduct along with applicable penalties for violation.
(Education Code Section 66300). The purpose of this policy is to provide uniform procedures to assure due process
when a student is charged with a violation of these standards. This policy will be administered by the Vice-President,
Student Services or his/her designee, generally agreed to be the program director.
Copies of this document and the booklet, STUDENT RIGHTS AND RESPONSIBILITIES AT CABRILLO COLLEGE, are
available in the Student Affairs Office, the Counseling Office, the Library, and the Office of Vice-President of Student
Services.
Academic Disqualification from Cabrillo Community College Study Travel Program
Students will become automatically ineligible for participation in a study program if at any time
prior to departure to the host country they are placed on academic probation, become subject to
dismissal, or are dismissed from Cabrillo College. In addition, students must have a cumulative
college GPA of 2.0 or higher to participate in the program.
Cabrillo Community College Alcohol and Drug Abuse Policy
The Drug-Free Schools and Communities Act Amendments of 1989 require institutions of higher education to implement a
drug prevention program, which includes the annual dissemination of the following policy on alcohol and drug use.
Cabrillo College is committed to the success of each student and, as a college; we realize that the use of alcohol and
drugs can be a major impediment to success.
There are both physical and psychological health risks associated with drug and alcohol use, including decreased
immunity, exhaustion, decreased muscle coordination, depression, confusion and paranoia, among other conditions. In
most cases, anyone who uses drugs and abuses alcohol can expect a decline in the quality of his/her life.
According to the STUDENT RIGHTS AND RESPONSIBILITIES AT CABRILLO COLLEGE, possession, use or distribution
of illicit drugs and alcohol on college property or during campus-related activities is subject to disciplinary action. This can
be up to, and including, expulsion from Cabrillo Community College, as well as punishment under California State law,
including from six months to one year in county jail, or up to five years in state prison.
Standards of Student Conduct for Cabrillo Community College Study Travel Programs
Violation: The conduct of students during Cabrillo Community College study abroad programs is of utmost importance.
Students, therefore, agree to conform to the standards of conduct consistent with the maintenance of the reputation of the
Cabrillo Community College District and, where applicable, the host educational institution. Students also agree to adhere
to all applicable rules, regulations, and policies of each educational institution.
Misconduct abroad refers to the student’s actions, which in the judgment of the program director jeopardizes the welfare
of students or the program. Violations of rules and regulations for which students enrolled in a study abroad program are
subject to disciplinary action, including dismissal from the program, include:
1.
2.
3.
4.
5.
6.
7.
Placing into jeopardy one’s own welfare, that of fellow students, the program directors, or the program.
Unauthorized absences from classes or required activities of the program.
Knowingly abusing the mores of the community.
Violation of the laws of the host country or regulations governing the host educational institution.
Interference in the domestic affairs of the host country or educational institution, including involvement in a
demonstration or
meeting in the host country which university or governmental authorities declare illegal.
Failure to adhere to any official Cabrillo Community College contract signed by the student regarding code of
conduct and
academic performance expectations.
Violation of rules, regulations, and policies of the Cabrillo Community College District.
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STANDARDS OF STUDENT CONDUCT (CONT’D)
Student Discipline Procedures
Notification of Hearing: Students charged with alleged violations of the Standards of Student Conduct will be provided a written
notice to meet with the program director or the associate director regarding the basis for possible disciplinary action. The notice
should normally be given at least one day prior to the scheduled appointment. The meeting with the program director and/or the
associate director shall contain the following:
1.
2.
3.
4.
5.
Copy of the Standards of Student Conduct for Study Travel Program will be given to the parties involved.
Written statement of charges against the student.
Reasonable opportunity at the meeting for the student to personally answer the charges.
Notification to the student of disciplinary action(s) that may be or will be taken.
Written notification to the student of further meetings if deemed necessary by the program director.
Disciplinary Action: If, after reviewing the situation with the student, the program director concludes that a disciplinary
action is appropriate, the program director shall deliver one or more of the following disciplinary actions.
Warning: Written or oral notice to the student that continuation or repetition of misconduct may be cause for further
disciplinary action, including immediate dismissal from the program.
Reprimand: Action placing on record (in the student’s cumulative folder) that the student’s conduct in a specific instance
does not meet the standards expected at the college. Anyone receiving an oral or written reprimand by the program
director is thereby notified that continued conduct of the type described will result in further disciplinary action against the
student, including dismissal from the program.
Dismissal from Study Travel Program: Disciplinary action terminating student’s participation in the Study Travel Program.
A dismissed student may be denied all privileges of the study abroad program including class attendance, housing, and
participation in program-sponsored activities for the duration of the program in which the student is enrolled. Dismissal
from a study abroad program is to protect the school from the immediate possibility of disorder or threat to the safety of
students or the program. It also serves as a penalty against the student as a result of the failure of his or her conduct to
meet the college’s standards of Student Conduct for Study Travel Programs.
The program director may dismiss a student for good cause from all classes and activities of the program. (Education
Code 76033).
The process for dismissing a student from a program is as follows. The student will be:
1.
2.
3.
4.
5.
6.
Given an oral or written notice of the charge against him or her.
Furnished with an explanation of the evidence against him or her, if the student denies the charges.
Given an opportunity to present his or her side of the situation to the program director, and if requested by the
student, to another student selected by the program director.
Furnished with oral and written instructions on how and when to return to the United States from the host country.
Informed that termination of his or her participation in the program for violation of the Standards of Student Conduct
shall not diminish or otherwise affect his or her obligation to make to the college any and all payments specified in
the contract for participation in the study abroad program.
Informed that the college will not be responsible for any additional expenses incurred after dismissal from the
program.
Miscellaneous
1.
Whenever the student to be suspended or dismissed is under 18 years of age, his/her parents or legal guardian
shall be notified in writing by Cabrillo Community College’s Vice-President of Student Services.
2.
Upon suspension or dismissal of a student for violation of Penal Code 245 (assault with a deadly weapon likely to
produce great bodily harm), the program director shall notify the appropriate law enforcement agency.
3.
The fact of any disciplinary action and the reasons therefore shall be recorded on the student’s records subject to
access, review, and comment by the student as authorized by the Family Educational Rights and Privacy Act (20
USC Section 2332g) and Education Code Section 76100 et. seq. All access or release of such records to members
of the public shall be according to applicable state and federal law.
4. Specified times may be shortened or lengthened by mutual concurrence of all parties.
I have read, understand, and hereby agree to the Cabrillo Community College District Standards of Student
Conduct for Field Trip/Study Travel Programs.
____________________________________
_________________________________________
Signature of Student
Signature of Parent or Legal Guardian if student under 18
__________________
years of age
___________________
Date
Date
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Cabrillo Community College District
Study Travel Program
PERSONAL HEALTH HISTORY FORM
(Modified from UC’s EAP Directors Manual)
This form is mandatory. This is a medical self-assessment to be completed
by you. Be sure to fill out the form completely. If you have any questions
regarding your health as it relates to your ability to participate in study
travel, please take this form to your doctor for consultation.
1.
Please print clearly. This is the only source of information about
your health that will be available in case of an emergency abroad.
2.
Make a copy of this form and carry it with you (in your passport).
3.
Return this form along with the Terms and Conditions, General Release
and Standards of Conduct forms to Cabrillo Community College’s
Study Travel office.
Picture here
_______________________________________________ ________________________________________________
Student Name
Program Location
________________________________________________ _______________________________________________
Student Contact Number
Email
_______
Language Level
_______________________________________________________________________
Housing Preference/Roommate Preference
_________________________________
SSN # or Student ID number
_____________________________________
Date of Birth
Sex ______
M F
_________________________________
Ethnicity
Person to notify in case of emergency: _______________________________________________
Name
_________________________________________________________________________________________________
Address
Phone
Medical Insurance: Company ______________________________________________
Policy Number ___________________
Blood Type _______
Tetanus Shot:
don’t know _______
0-5 years _______
5-10 years _______
don’t know _______
Health problems: List any recent or continuing health problems:
_____________________________________________________________________________
_____________________________________________________________________________
Personal Medical History: Check if you have ever had any of the following
Condition
Anemia
Asthma/hay fever/allergy
Back problem
Bladder/kidney problem
Epilepsy /convulsion
High blood pressure
Heart problem
Jaundice/hepatitis
Ulcer/stomach problem
Anorexia/bulimia
Infectious mononucleosis
Thyroid problem
Psychiatric problems
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Yes
No
Date
4
Migraine headaches
Alcohol problems
Substance abuse
Surgery
Cabrillo Community College District
Study Travel Program
PERSONAL HEALTH HISTORY FORM (CONTINUED)
Drug Allergies: Check any drug allergies and briefly describe what happened
Drug
Penicillin
Novocain/local anesthetic
Sulfa
Other
Yes
No
What Happened
Yes
No
Who
Family Medical History:
Condition
Asthma/allergies
Diabetes
Heart Disease
High blood pressure
Sickle cell
Immunizations: Immunization is not required for any disease by the United States or any country you will be entering.
Cabrillo Community College advises you to check with your physicians and abide by their recommendations. Please list
any immunizations you have had and when they were given.
Immunization
Date
Tuberculosis: Have you ever lived in close contact with anyone who had tuberculosis? _______ Yes _______ No
Previous skin test:
Negative _____ Year _______
Positive _____ Year _______
never tested _____
TB medicines taken ____________________________________
Medicines: List any medications (pills or injections) you take regularly:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Authorization for Medical Treatment and Waiver
I wish to (and if under 18 years of age also my parent or guardian authorizes my son/daughter to) participate in the
Cabrillo Community College-sponsored program referenced above (hereinafter “Program”). In order that I, (my
daughter/son) may receive the necessary medical or dental treatment in the event of an emergency whereby I (she/he)
may sustain injury or illness, during participation in this Program, I authorize any school official to consent to and obtain
necessary medical or dental treatment, including x-rays, examination, anesthetic, medical or surgical diagnosis or
treatment or hospital care for such injury or illness during the Program and I hereby release, discharge, indemnify and
agree to hold Cabrillo Community College and the Cabrillo Community College District, the District’s governing board and
College and each of their trustees, employees, agents, coaches, teachers, volunteers, and representatives harmless in
the exercise of such authority. I hereby further acknowledge that neither Cabrillo Community College, nor any of the
persons named above have any obligation to seek such treatment. Should the need arise; any information provided
herein may be given to any health care provider. I/we understand that the resulting expenses may be the responsibility of
the participant.
_______________________________________________ _______________________________________________
Signature
Signature of Parent or Legal Guardian if student under 18
years of age
______________________________________________ ______________________
Please print name
Date
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