Checklist – Keep this page for your information!!!
(Print the form-Click here-Word Document)
This is not a complete list, but rather a guide to help in preparation for the overnight fieldtrip. If you have any question, ask during the pre-trip meetings or contact:
Checklist - Tear off this page and keep for your information!!!
October 20, 21st, 2007
October 19th, is optional and by request. 6 seats available.
This is not a complete list, but rather a guide to help in preparation for the fieldtrip. If you have any question, email one of the contacts below.
Contacts: Max maxey@unt.edu
Joaquin spanishjack@earthlink.net
Will wflanagan@unt.edu
Personal clothing: (Dress in layers)
1. T-shirt and long pants.
2. Long sleeved shirt, sweatshirt or jacket.
3. Socks, underwear, and sturdy shoes or boots.
4. Hat, bandana, or cap.
5. Raingear.
Personal items: (Field guide provided by instructor)
1. Toilet articles, toilet paper, washcloth, and towel.
2. Daily and emergency medication.
3. Pocketknife, flashlight, camera, sunglasses and binoculars (optional).
4. Sunscreen, insect repellent, small first aid kit.
5. Clipboard, pencil, and backpack.
Camping gear: 1. Tent, stakes, hammer, sleeping bag, and pad.
2. Large plastic leaf bag for keeping things dry.
3. Knife, spoon, fork, and plate.
Food: (Food is your responsibility)
1. Breakfast Saturday 20th, morning before arriving at the UNT parking lot at 7:45 am.
2. Bring a sack lunch for Saturday lunch.
3. Bring snack food for Sunday during the day.
No consumption of alcohol, or banned substances in University Vans private cars or during fieldwork.
Fill out all pertinent information on the following pages and turn in to Max, Joaquin or Will.
Geology Field trip to Southeast Oklahoma
October 19-21, 2007.
1 The field trip is limited to the first 35 individuals.
Students going up October 19th, will meet at the parking lot of the west EESAT at 12:00 to load supplies and gear.
2. The trip officially begins 7:45 am Saturday, October 20th, 2007. Arrive at the EESAT building west parking lot, at 7:45 am to load equipment.
3. Ground Rules
a. No form of alcoholic beverage may be consumed or in your possession during the hours of the field trip, approximately 7:45 am to 5:00 pm Saturday and Sunday.
b. No illegal drugs.
c. Oklahoma laws will be followed.
d. Be aware that Oklahoma has open container laws.
4. All participants must complete a University of North Texas Waiver of Liability.
(See attached)
5. A $20.00 cash (no checks) fee is required with respect to this field trip. Students are responsible for their expenses.
Print Name ____________________ Phone _________________________
Best time to call _______ am or pm Email _________________________
Lecture instructor ___________________ Lab instructor ______________________
I _______________________________, have read, understand, and hereby agree to the above stated conditions.
____________
Date
MEDICAL TREATMENT PERMISSION FORM
STUDENT: _____________________________________________
Name
___________________________________________________________
Address
___________________________________________________________
Phone Number
PARENT: ____________________________________________________________
Name of Parent or Legal Guardian
____________________________________________________________
Address
___________________________ ______________________________
Home Phone Work Phone
INSURANCE: ____________________________________________________________
Company
____________________________________________________________
Policy Number
____________________________________________________________
Phone Number for Pre-certification
I/Parent or Guardian of the above-named, hereby give(s) permission, consent, and authorization for any medical treatment deemed necessary to any Hospital and/or Medical Center and physicians thereof. I appoint the activity coordinator and/or director as my lawful agent with power to authorize and consent to the administration of medical treatment during the trip to Southern Oklahoma and adjacent areas.
Please list all allergies, restrictions, or health exceptions:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
This form should be returned to the department prior to leaving on the activity. In case of such an accident or illness, I give permission for me/my child to be given medical treatment as deemed appropriate. I will assume responsibility for any medical bills incurred by me/my child.
__________________________________________
Signature of Participant, if over 18 years old, OR
Signature of Parent or Legal Guardian
__________________________________________ ________________
Printed Name of person signing Date
POSSIBLE INJURIES WHICH MAY OCCUR
There are risks involved when participating in the field trip to Southern Oklahoma and adjacent areas. Some of the possible injuries and bodily harm that can occur through participation in the activity are listed below. This list is provided to make the prospective participant aware of the possibilities of injuries that may be sustained. The individual is completely responsible for his/her own safety and health.
POSSIBLE INJURIES: strains, sprains, pulls, tears, cramps, infections, rashes, vomiting, bruises, contusions, wounds (abrasions, incisions, lacerations, punctures, avulsions), insect bites, snake bites, dislocation, blisters, nosebleeds, broken bones, fractures, choking, respiratory or heart failure, heat exhaustion, heat stroke, fainting, nerve damage, shock, paralysis, concussion, and in an extreme case - death.
BODY AREAS THAT MAY BE AFFECTED OR INVOLVED IN INJURY: head, face, eye, ear, jaw, teeth, mouth, neck, nose chest, abdominal, back, arms, elbow, hands, fingers, wrist, shoulders, genital organs, scalp, bones, leg knee, hip, ankle, feet toes, internal organs, nerves, muscles, ligaments, cartilage, joints, tendons, spinal cord, arteries and veins, brain, etc.
I/my child have/has reviewed the above information and am/is aware of the risks involved in participating in the activity and the possible injuries that may occur. I/my child freely and voluntarily agree(s) to participate in any and/or all of the activities taking place on this field trip.
IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it, and sign it voluntarily as my own free act and deed; no oral representations, statement or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate, and complete consideration fully intending to be bound by same.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on this the _____ day of ________________, 2007.
PARTICIPANT: SPONSOR:
__________________________________ ______________________________
Signature Signature
__________________________________ ______________________________
Printed Name Printed Name
______________________________
__________________________________ Date
Parent must sign if under 18 years old
UNIVERSITY OF NORTH TEXAS
WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT
1. In consideration for receiving permission to participation in the field trip to Southern Oklahoma and adjacent areas and other valuable consideration through the Department of Geography at the University of North Texas, I hereby RELEASE, WAIVE, DISCHARGE, and COVENANT NOT TO SUE The University of North Texas ("UNT"), the Department of Geography of UNT, the Board of Regents of UNT, and the officers, servants, agents, students, and/or employees of UNT and/or the State of Texas (hereinafter referred to collectively as RELEASEES), from any and all liability, claims, demands, actions and/or causes of action whatsoever arising out of or related to any loss, damage, injury, illness, and/or disease, including death, that may be sustained by me, or any loss or damage to any property belonging to me, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES, or otherwise while participating in such an activity, or while in, on, or upon the premises where the activity is being conducted or in transportation to and from said premises.
2. To the best of my knowledge, I can fully participate in this activity. I am aware of the risks and hazards connected with the activity, including but not limited to the risks as noted herein, and I hereby elect to voluntarily participate in said activity, and to enter the above-named premises and engage in such activity knowing that the activity may be hazardous to me and my property. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE, OR PERSONAL INJURY, INCLUDING DEATH, that my be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such an activity, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASEES or otherwise.
3. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage or costs, including, but not limited to medical costs, court costs and attorney's fees, that may be incurred due to my participation in the said activity, WHETHER CAUSED BY NEGLIGENCE OF RELEASEES or otherwise.
4. It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assigns and personal representative, if I am not alive, and shall be deemed as a RELEASE, WAIVER, DISCHARGE, AND COVENANT NOT TO SUE the above-named RELEASEES. I hereby further agree that this Waiver of Liability and Agreement of Understanding shall be construed in accordance with the laws of the State of Texas.
5. I UNDERSTAND THAT THE UNIVERSITY OF NORTH TEXAS WILL NOT BE RESPONSIBLE FOR ANY MEDICAL COSTS ASSOCIATED WITH ANY INJURIES OR ILLNESSES I MAY SUSTAIN IN CONJUNCTION WITH MY PARTICIPATION IN THIS ACTIVITY.
6. I further agree to become familiar with the rules and regulations of the University of North Texas concerning conduct and not to violate said rules and regulations or any other directive or instruction made by the person or persons in charge of this activity.
7. I also agree that I should and I am urged by the University of North Texas to obtain adequate health and accident insurance to cover any personal injury or illness to myself which may be sustained during my participation in this activity.
IN SIGNING THIS RELEASE AS A PARTICIPANT IN THIS ACTIVITY, I ACKNOWLEDGE AND REPRESENT THAT I have read the foregoing Waiver of Liability and Agreement of Understanding, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate, and complete consideration fully intending to be bound by the same. I FURTHER ACKNOWLEDGE AND UNDERSTAND THAT UNT IS NOT RESPONSIBLE FOR SUPERVISION OF PARTICIPANTS IN THIS ACTIVITY.
IN WITNESS WHEREOF, I have hereunto set my hand on this the __________ day of _______________, 2007.
PARTICIPANT: SPONSOR:
__________________________________ ______________________________
Signature Signature
__________________________________ ______________________________
Printed Name Printed Name
______________________________
Date
WITNESS:
_________________________________
Signature
_________________________________
Printed Name
_________________________________
Telephone Number
_________________________________
Address
_________________________________
City, State, Zip Code