Home »Non-Returning Students We’re sorry you won’t be returning in the fall. Club/Organization* Trip Name* Destination (City, State)* Trip Start Date* MM slash DD slash YYYY Trip Start Time* : Hours Minutes Trip End Date* MM slash DD slash YYYY Trip End Time* : Hours Minutes Requesting Member Name* First Last Requesting Member Email* Enter Email Confirm Email Your Club Position*PresidentVice PresidentTreasurerSecretaryOther E-Board PositionGeneral MemberClub Advisor*NameEmail Additional Club Advisor (if applicable)NameEmail Trip Chaperone*NameE-Mail Additional Trip Chaperone (if applicable)NameE-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 NumberContact Person E-Mail Facility/Hotel/Overnight Accomodations* Facility Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 documentTravel 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)QuantityType of Room Click the + button to add another type of roomDo 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 NameEmergency NameEmergency Phone # Press the + button to add another studentPress the + button to add another studentStudent NameEmergency NameEmergency Phone # Press the + button to add another studentPress the + button to add another studentStudent NameEmergency NameEmergency Phone # Press the + button to add another studentPress the + button to add another studentStudent NameEmergency NameEmergency Phone # Press the + button to add another studentPress the + button to add another studentStudent NameEmergency NameEmergency Phone # Press the + button to add another studentPress the + button to add another studentStudent NameEmergency NameEmergency Phone # Press the + button to add another studentPress the + button to add another studentStudent NameEmergency NameEmergency Phone # Press the + button to add another studentPress the + button to add another studentStudent NameEmergency NameEmergency Phone # Press the + button to add another studentPress the + button to add another studentStudent NameEmergency NameEmergency Phone # Press the + button to add another studentPress the + button to add another studentStudent NameEmergency NameEmergency Phone # Press the + button to add another studentConference/Event Registration/Admission Cost per StudentTransportation Cost per StudentLodging Cost per StudentFood Cost per StudentPlease visit www.gsa.gov for per diem ratesMiscellaneous Cost per Student (Please explain cost(s) in detail)Total Cost per StudentTotal Student CostNumber above times number of students participatingTotal Number of Chaperones Travelling*Student Life & Activities will fund one chaperone for every ten students travelling.Conference/Event Registration/Admission Cost per ChaperoneTransportation Cost per ChaperoneLodging Cost per ChaperoneFood Cost per ChaperonePlease visit www.gsa.gov for per diem ratesMiscellaneous Cost per Chaperone (Please explain cost(s) in detail)Total Cost per ChaperoneTotal Chaperone CostNumber above times number of chaperones participatingWill you be applying to the SLB Finance Committee for funding?* YES NO $1.00 - $3500.00=60% funded by ASBCC; $3501-$7000.00=40% funded by ASBCC; more then $7000.00=$2800.00 funded by ASBCC. Please note, if requesting funding assistance from the SLB Finance Committee, proposals must be submitted with at least 2 full weeks prior to event date for consideration.TOTAL TRAVEL COST (answer 0 if none)*If you have other information to be considered, please upload a file hereMax. file size: 50 MB.(Itinerary, Conference Schedule, etc...)CommentsThis field is for validation purposes and should be left unchanged. Δ