Non-Returning Students

Club/Organization*

Trip Name*

Destination (City, State)*

Trip Start Date*

Trip Start Time*

:

Trip End Date*

Trip End Time*

:

Requesting Member Name*

First Last

Requesting Member Email*

Enter Email Confirm Email

Your Club Position*

Club Advisor*

Name	Email

Additional Club Advisor (if applicable)

Name	Email

Trip Chaperone*

Name	E-Mail

Additional Trip Chaperone (if applicable)

Name	E-Mail

Who may attend? (Please check all that apply)*

BROOKDALE Students
Faculty/Staff
Community Members
Club/Org Members ONLY

What is the purpose of travel? Please provide as much detail as possible.*

How Does This Event Fit Into The Mission Of Your Organization?*

Would you also like to propose this event to fulfill your Club/Org's Community Service Requirement?*

YES
NO

Outside Agency (if applicable)

Contact Person from Outside Agency

First Last

Contact Person Phone Number

Contact Person E-Mail

Facility/Hotel/Overnight Accomodations*

Facility Address*

Street Address Address Line 2 City State ZIP Code

Facility Phone Number*

Special Events/Activities Planned (please list the activity, date time, facility location and an emergency phone # if available)

You can also upload this information as a seperate document

Travel Arrangements (Please check all that apply)*

Airplane
Airport shuttle
Charter Bus
College Van
Train
OTHER

Please Note How Many and What Type of Room accommodations you Need: (ie, 2 doubles, or 1 single, 2 triples)

Quantity	Type of Room

Click the + button to add another type of room

Do you need a cash advance to travel?*

YES
NO

Please Note: cash advances are only available to Brookdale Employees, can take up to six weeks to process before a trip, and must be returned within five business days after a trip with itemized receipts.

Total number of students travelling*

Names of students participating (including name and phone number of emergency contact for each)*

Student Name	Emergency Name	Emergency Phone #