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Short-Term, Off-Campus Program Waiver and Release Form

All participants of short-term, off-campus programs, should print this form and submit it to their program director after signing. 

By signing this document you are confirming that you have read, understand and agree to the terms on the following Agreements, Policies, Forms and/or Waivers:

  1. Health & Emergency Contact Information (to be submitted online)
  2. Waiver of Rights and Release of Liability Agreement
  3. Program Participation Agreement
  4. Authorization to Release Protected Health and Dietary Information
  5. Code of Honor 

All of the above documents are available for download from this website and paper copies will be made available to any applicant upon request. I have read and understand the above documents and I agree to all terms and conditions of these documents made effective with the date of my signature recorded below.

____________________________
Applicant’s full name (Print)    

_____________________________     ______
(Signature of Applicant/Participant)      Date

____________________________
Parent/Legal Guardian's full name (Print)   

_____________________________      ______
(*Signature of Parent/Legal Guardian)    Date            

___________________________________        _____________________
(Short-Term, Off-Campus Program)                           CSB/SJU ID #

*Parent or Guardian signature is necessary unless the student is not considered a dependent for federal income tax or financial aid purposes.   

SHORT-TERM, OFF-CAMPUS PROGRAM
WAIVER AND RELEASE FORM

Instructions

At least two weeks before departure for your off-campus program, please:

  1. Complete the on-line Health & Liability Information for Off-Campus Program Travel Form
  2. Return this signed waiver form to your program director.  Please note you only need to print this one page.  The 5 attachements are for your reference.