UNIVERSITY OF THE INCARNATE WORD EXCURSION APPROVAL REQUEST Name of the Organization: _________________________________ Date Recorded: _______________ Contact Person: _________________________________________ Phone: _______________________ Date of Event: ________________________________________________________________________ Description of Proposed Event: _________________________________________________________ Mode of Transportation: _______________________________ Driver's Name: __________________ *If an outside company provides transportationlist address and phone number. Company's Name: ____________________ Address/Phone Number: __________________________ Organization leaders/sponsors agree to insure that all drivers ____ years older are licensed to drive the vehicles for the event and that participants wear seat belts when provided. The driver must provide proof of insurance if a personally owned vehicle is to be operated. Seat belts must be provided for each passenger and must be worn, unless riding in an approved bus without seatbelts. Lodging Accomodations: Name: __________________________________________________________________ Address: ________________________________________________________________ Phone Number: __________________________________________________________ Time/Place of Departure: _______________________________________________________________ Time/Place o Return to UIW: ____________________________________________________________ Please attach an itinerary of te trip. Liability waivers for all participants must be on file in the Office of Student Life prior to the event. List the names of faculty/staff advisors who will be in attendance on the excursion: ________________ ___________________________________________________________________________________ We, the undersigned, certify that we are officers of the above named registered student organization and that the event specified will be held in accordance with all federal, state, or local laws or regulations regarding such evets. Further, we assume collective and individual responsibility for the orderly conduct of the event in accordance with all UIW policies. _______________________ ______________________ _______________________ Officer Signature Date Officer Signature Date Advisor Signature (goldenrod copy)     _______________________ _______________________ ________________________ Position Phone Position Phone Date Phone APPROVALS _______________________________________ __________________________________ Director, Student Center & Leadership Activities Date Dean of Student Life (for alcohol) (Original copy)   ___________________________________ __________________________________ Director of Special Events Date Director of Campus Security (for alcohol) Date (pink copy)   LIST OF PARTICIPANTS EVENT: ________________________________________________________ DATE(S): _______________________________________________________ Name ____________________________________________ SS#_____________________ Signature__________________________________________ Emergency Contact Name_____________________________ Phone # _________________ Emergency Contact Address____________________________________________________ Name ____________________________________________ SS#_____________________ Signature__________________________________________ Emergency Contact Name_____________________________ Phone # _________________ Emergency Contact Address____________________________________________________ Name ____________________________________________ SS#_____________________ Signature__________________________________________ Emergency Contact Name_____________________________ Phone # _________________ Emergency Contact Address____________________________________________________ Name ____________________________________________ SS#_____________________ Signature__________________________________________ Emergency Contact Name_____________________________ Phone # _________________ Emergency Contact Address____________________________________________________ Name ____________________________________________ SS#_____________________ Signature__________________________________________ Emergency Contact Name_____________________________ Phone # _________________ Emergency Contact Address____________________________________________________ Name ____________________________________________ SS#_____________________ Signature__________________________________________ Emergency Contact Name_____________________________ Phone # _________________ Emergency Contact Address____________________________________________________ Name ____________________________________________ SS#_____________________ Signature__________________________________________ Emergency Contact Name_____________________________ Phone # _________________ Emergency Contact Address____________________________________________________ Name ____________________________________________ SS#_____________________ Signature__________________________________________ Emergency Contact Name_____________________________ Phone # _________________ Emergency Contact Address____________________________________________________