Channel Islands 2016
Application Packet
Student Name:
PACKET
 Participant Contacts, Health & Insurance Form
 Trip Expectations
 CSUSM Waiver & Release of Liability
 Physician Clearance Form
ADDITIONAL DOCUMENTS
 Participation Fee - Non-refundable
 Copy of Health Insurance card
 Copy of Driver’s License
 Copy of CSUSM ID
For office use
 Form Completed
Staff Signature: ________
__________ Date: ___________
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PARTICIPANT CONTACTS, HEALTH & INSURANCE FORM
CONTACTS
NAME:
GENDER:
@cougars.csusm.edu PHONE#:
EMAIL:
DATE OF BIRTH: _______________AGE: ______ SCHOOL ID#: ________________________
LOCAL ADDRESS:
ANTICIPATED GRADUATION:
MAJOR:
GENERAL HEALTH & FITNESS INFO
HEIGHT: ______________ WEIGHT:______________
Do you have any allergies? Foods, environment, insect bites or bee stings? ________________ . YES NO
Do you require any medication?
_________________________________________ . YES NO
Do you have any dietary restrictions? Please specify. __________________________________ . YES NO
Are you allergic to any medication? ________________________________________________ . YES NO
Do you exercise regularly? ______________________________________________________ . YES NO
Activity
Frequency
Duration/Distance
Intensity Level
(Easy/Moderate/Competitive)
Do you smoke? If so, how much? __________________________________________________ . YES NO
Swimming ability (CHECK ONE): ______ Non-swimmer ____ Recreational ______Competitive
INSURANCE INFORMATION
NO One will go on the trip without Health Insurance Coverage. If you do not already belong to a regular health program, we
suggest a short-term policy, which you may buy from your local insurance agent. Non-U.S. citizens, please indicate your primary
health coverage and any out-of-country travel insurance.
NAME OF PROVIDER: __________________________________________ PHONE#:
INSURANCE ADDRESS:
NAME OF POLICY HOLDER: __________________________ GROUP POLICY#:
SUBCRIBER POLICY #:______________________POLICY HOLDER’S #:
I consent and authorize Hugo Lecomte to release to the staff at California State University San Marcos, health information
concerning my ability to participate in the Channel Islands Weekender. I understand this consent is revocable except to the extent
action has been taken. Authorization is not valid beyond one year from date of signature. Further disclosure or release of my
health information is prohibited without specific written consent of person to whom it pertains.
Print Name
Signature
Date
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TRIP EXPECTATIONS
I understand that I am a travel guest away from the University. I understand that my behavior reflects upon my university,
my family, and Campus Recreation. I agree that I will act according to the laws of the land as well as the socially acceptable
and polite norms of where I am visiting. I also agree as follows:
1. Student will be personally responsible for all, insurance, and personal expenses. Trip covers cost for
transportation and meals as stated on itinerary.
2. University reserves the right to terminate the program or any part of the program if the health or safety of the
participants is deemed to be at risk. Reasons for such termination include, but are not limited to, U.S.
Department of State Travel Warnings for the Program location, outbreaks of contagious diseases at the Program
location, severe weather, or where they might reasonably affect Student, acts of war or terrorism that could
affect Student. In the event of such termination, University will make all reasonable efforts to assist Student to
return home.
3. University reserves the right to alter or change the schedule, itinerary, or the accommodations for room and
board when acts, occurrences or events make it necessary or desirable, in the discretion of University, to make
the modification.
4. No alcohol or other substances including tobacco, cigarettes, or illegal drugs are allowed on the trip. If a
student is in violation of campus or trip policies on behavior, the student will be immediately dismissed and is
personally responsible for their bus or air transportation home.
5. Payments made pursuant to this Agreement do not include any items not expressly identified in Paragraph 1
above, such as expenses for immunizations, emergency medical costs, personal insurance, food and beverages
planned on your own, telephone or other hotel expenses, transportation from home to point of departure and
return if dismissed due to behavior, tips, personal transportation, porter services, or optional tours.
6. Student shall obey all applicable laws of the state or host countries and shall hold University blameless and not
responsible for any liability or consequences caused by Student’s violation of law.
7.
Campus Recreation and the University are not responsible for Student’s welfare during periods of independent
travel or during absences from the program or during free time.
Print Name
Signature
Date
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This Form must be Completed and Signed by Your Medical Provider!
Campus Recreation – Channel Islands
Health Clearance Form
In the interest of safety, of yourself and other participants, please have your Medical Care Provider you have seen the
most, complete and sign this form.
STUDENT’S NAME: ____________________________________
The student (name stated above) has applied to participate in the Channel Islands Weekender program led by Campus
Recreation, University Corporation, at California State University San Marcos.
The Channel Islands Weekender will occur on Channel Island, Ventura, CA April 22th-April 24th.
The Channel Islands Weekender program includes, but is not restricted to, the following characteristics:

Spend many hours of the day traveling outdoors and may include some camping.

Travel by car on roads and on foot over improved and unimproved roads, rugged trails, off-trail terrain and boat.

Activities may be strenuous, physically, and emotionally. Includes hiking through mountainous and other terrain.

The environment for this program is usually in remote places, sometimes hours from medical facilities, where
risks and hazards may include flowing, deep and/or cold water; insects, snakes, predators, and large animals;
forces of nature, including weather which may change to extreme conditions.
By signing below, I certify that I have reviewed the activities and the health history of the individual listed on this form. It is
my opinion that this individual may participate in the Channel Islands Weekender program, with the characteristics listed
above, and is capable of taking part in these activities.
YES
NO
Comments:
Provider’s Signature
Date
Printed Name
License #
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