Participant Name: ________________________ Sponsoring Club: _______________________

NSM-ICC Funding Request Packet: TRAVEL The NSM-ICC prefers that all funding request proposal packets be submitted prior to event for allocation consideration. We understand that there may be situations where retroactive funding may be necessary. These will be considered on a case-by-case basis. >> Pre-Travel Forms (Must be submitted prior to travel even if retroactive funding will be requested. If these forms are NOT completed and approved prior to travel, reimbursement cannot be provided per ASI regulations.) Delegate Contract: If you are staying at a hotel, please include hotel information even if you do not plan to request funds for hotel stay. PARTICIPANT/TRAVELER MUST READ AND SIGN THIS DOCUMENT. Release of Liability: Form must include information for conference. PARTICIPANT/TRAVELER MUST READ AND SIGN THIS DOCUMENT. Field Trip Participation: ONLY REQUIRED WHEN TRAVELING IN A GROUP In the case of a group traveling to a conference, the form should be filled out only once and include all the traveling students. Vehicle Form: A copy of driver’s license, driver’s auto insurance card, and a copy of your Defensive Driver’s Certificate must be turned in. This portion of the packet must be turned in at least 2 weeks prior to travel. Must be completed fully, signed AND initialed. Failure to turn this in far enough in advance for ASI processing may result in no reimbursement for driving. ONLY REQUIRED BY PARTICIPANTS WHO ARE DRIVING. If you are not driving, skip this form. Executive Senate Travel Request Form: The summary of expenses should include ALL expenses for the trip regardless if you are being reimbursed for them or not. If receiving funding from a department (e.g. Biology Department, Chemistry & Biochemistry Department, etc.), check “yes,” and in the box below include information for the department funding only – not the ICC funding. If not receiving department funding, simply check “no.” ***If the proposal shall be submitted for retroactive consideration, please submit the above forms prior to departure. Failure to do so will result in a retroactive proposal not being considered for funding.

 

 

>> Funding Proposal Documents (Must be turned in prior to travel unless seeking retroactive funding).

A complete travel request packet includes these documents, in addition to the pre-travel forms. Submit the completed packed to the ICC representative for review. The NSM-ICC meets every Friday; finalized packets are

due to the ICC the prior Friday in order to be reviewed and considered for the next week’s agenda.

Cover Letter: Basic information and a paragraph stating the purpose of the travel, the benefit to the student and CSUF, and why funding is needed to attend the conference/event.

Allocation Request Form: Conference/Event information with total amount of travel costs corresponding to Line 8077: Travel. Please include the total.

NSM-ICC CLUB REPRESENTATIVE MUST SIGN THIS DOCUMENT

Letter of Confirmation from Research Advisor:  If presenting, this letter shall be written by traveler’s research professor/advisor confirming participation in the conference.

LETTER MUST BE SIGNED BY RESEARCH PROFESSOR/ADVISOR.

Verification of Acceptance to Present Work:  This is typically an email that was sent to traveler stating that the abstract has been accepted to be presented at the conference.

ONLY REQUIRED IF YOU ARE PRESENTING YOUR WORK.

Copy of Abstract: We require both a DIGITAL COPY to be submitted to the Vice Chair and HARD COPY to be submitted with this packet. ONLY REQUIRED IF YOU ARE PRESENTING YOUR WORK. >>> Presentation of Proposal: The traveler must attend the NSM-ICC meeting to make the request in person, unless there is an excused reason he/she cannot attend. The student should be prepared to share the justifications provided in the Cover Letter. >>>>Post-Travel Forms (Must be submitted to the Vice Chair within 15 days of returning)

Written Report:  This report should be a minimum of 350 words and summarize the topics/panels/speakers attended and what was learned from them, what will be brought back to the university by the student, and how CSUF and ASI benefit from the student’s attendance at the conference.

Oral Presentation: Given to the club that sponsored the student’s travel.

All Original Itemized Receipts: Speak with your NSM-ICC Club Representative for details on what the ICC will reimburse, and reference the Post-Travel Paperwork Checklist that you should receive at the time when you are allocated the funds.

 

 

>>>> Annual Science and Mathematics Symposium Requirements: Please initial next to ONE of the following that pertains to you and to your level of participation at the conference for which you are receiving funding. Then read the corresponding statement and sign. You will be contacted in the Spring with details regarding presenting/volunteering. _______ ACTIVE (Presenting research) I, _________________, understand that by presenting research at a conference and obtaining funding from NSM-ICC, I am required to present my research at the Annual Math and Science Symposium in the Spring. Signature: ____________________________________ Date: _________________ _______ NON-ACTIVE (Not presenting research/only viewing or attending) I, _________________, understand that by taking a non-active role at a conference and obtaining funding from NSM-ICC, I am required to volunteer at the Annual Math and Science Symposium in the Spring. Signature: ____________________________________ Date: _________________ PARTICIPANT SIGNATURE: By signing below, I understand and agree to fulfill all necessary requirements of the items completed on the above checklist. I also agree to participate as an NSM-ICC student representative at the funded event and after. In addition, to the best of my knowledge, I am turning in a complete funding request proposal packet. ______________________ _______________________________ ___________________ Printed Name Signature Date NSM-ICC CLUB REPRESENTATIVE SIGNATURE: By signing below, I agree that I have looked over the funding request proposal packet with the submitting participant. I have verified that all necessary items have been fully completed and are properly organized. I have verified that all forms have been typed and signed where applicable. To the best of my knowledge, I have verified that this funding request proposal packet is complete and ready to be sent forward to the Vice-Chair/Director of Finances, and to be considered by the NSM-ICC members. ______________________ ______________________________ ___________________ Printed Name Signature Date

AssoclatedStudents lnc.

Emergency Contact Phone Number(s):

Dates of Travel:

Means of Travel: air Ll car Ll train

Departure Flight Numberffime

Arrival Flight Number/Time;

l-{r/

1.

2.

signing below, I agree to the following:

I will attend and participate in ALL aspects of the conference, i.e. attending a presentation during each session offeredas wellas attending generalmeetings and meals.

I realize that I am a representative of the Associated Students, Califomia State University, Fullerton, Inc., and that I

have been chosen by my organization to represent it and its interests. As such a representative, I understand that anyactions I take at the conference will negatively or positively affect opinions of others about our organization andCalifornia State Universi$, Fullerton.

As a delegate, I will engage in behaviors that are responsible and mature. Intoxication, use of illegal substances,abusive or inappropriate behavior may result in dismissalfrom the delegation and conference.

I understand that rny behavior at this conference may affect negativeiy or positively any future conference funding fnomthe ASI or ICC for my organieation.

ln accordance with ASI Policy Statement #213, I understand that I am to provide a one-page, written report to ASILeader and Program Development (TSU 269) no later that 15 school days after I retum from the conference. Further, I

understand that I am to provide a presentation to my organization, ICC or ASI Board within that same time period.

I hereby certify that I am a duly enrolled student in good academic standing (2.0 for undergraduate students, 3.0 forgraduate students) at California State University, Fulierton.

I understand that violation of any of the above regulations may require me to reimburse the ASI for any expendituresincurred for my participation at the conference.

4.

o"

7

Signature Date

NSM-ICC Club:

RELEASE OF LIABILITY. PROMISE NOT TO SUE. ASSUMPTION OF RISK ANI). AGREEMENT TO PAY CLAIMS

Activity:

Activity Date(s) and Time(s):Activitv Location(s):

in consideration for being aiiowed to participate in this activity, on behalf of myself anci mynext of kin, heirs and representatives, I release from all liability and promise not to sue the

State of California; the Trustees of The California State University; California State University,Fullerton and their employees. officers, directors, volunteers and agents (collectively"University") from any and all claims, including claims of the University's negligence,resulting in any physical'or psychological injury (including paralysis and death), illness,

damages, or economic or emotional loss I may suffer because of my participation in this

Activity, inciuding travel to, from and during the Activity.

I am voluntariiy participating in this Activity. I am aware of the risks associated with travelingtoifrom and participating in this Activity, which include but are not limited to physical orpsychological injury, pain, suffering, illness, disfigurement, temporary or perrnanent disability(including paralysis), economic or emotional loss, and/or death. I understand that these injuriesor outcomes mav arise from my own or other's actions, inaction. or negligence: conditionsrelated to travel; or the condition of the Activity location(s). Nonetheless, I assume all relatedrisks, both known or unknown to me, of my participation in this Activity, including travelto, from and during the Activif"v.

I agree to hold the University harmless from any and all claims, including attorney's fees or

damage to my personal propertl,. that may occur as a result of my participation in this Activity,including travel to, from and during the Activity. If the lJniversity incurs any of these types ofexpenses, I agree to reimburse the University. If I need medical treatment, I agree to be

financially responsible for any costs incurred as a result of such treatment. I am aware and

understand that I should carry my own health insurance.

I am 18 years or older. I understand the legal consequences of signing this document,including (a) releasing the University from all liabilify, (b) promising not to sue the

Universify, (c) and assuming all risks of participating in this Activity, including travel to,

from and during the Activity.

I understand that this document is written to be as broad and inciusive as legally permitted by the

State of California. I agree that if any portion is held invalid or unenforceable, I will continue to

be bound by the remaining terms.

I have read this document, and I am signing it freely. No other representations conceming the

legal effect of this document have been made to me.

Particinant Sisnature :

Date:Participant Name (print):

If Participant is under 18 yeurs of uge:

I am the pareni or legal guardian ofthe Participant. I understand the legal consequences ofsigning this document, including(a) releasing the University from all liability on my andthe Participant's behalf, (b) promising not to sue on my and the Participant's behalf' (c)

and assuming all risks of the Participant's participation in this Activity, including travel to,from and during the Activity. I allow Participant to participate in this Activity. I understand

that I am responsible for the obligations and acts of Participant as described in this document. I

agree to be bound by the terms of this document

I have read this two-page document, and I am signing it freely. No other representations

conceming the legal effect of this document have been made to me.

Signature of Minor Participant' s Parent/Guardian

Name of Minor Participant's Parent/Guardian (print) Date

Minor Participant' s Name

ffiF*ir- ffid*E ny i ro n.mental H ea lth and I ns tr uct ional S afe ty 6 5 7 ) 2 7 B-7 2 3 3Ris k Management (6 5 7) 27 8-7 3 4 6

College:

. ACADEMIC FIELD TRIP PARTICIPANT LIST

Department:

Dept._ Course # Schedule # Instructor

Activity Description/Title :

Field Trip Begins:

Date: Time: Location:Field Trip Ends:

Date: I lme: Location:

Faculty/Staff Contact in case of emergencl,:Phone:

PARTICIPANT LIST

Participant Name In Case Of Emergency CallNameiReiationshi

Phone NumberInclude Area Code

Natural Sceince and Mathematics

Upon expiration of your driver’s license and/or insurance, you must reactivate your authorization by updating your information in TSU 218.

Updated January 2013

ASSOCIATED STUDENTS California State University, Fullerton, Inc.

AUTHORIZATION TO USE PRIVATELY-OWNED/RENTED VEHICLE

STUDENTS

This form authorizes the use of a personal vehicle or a rental vehicle in the conduct of official business for Associated Students, CSUF, Inc. (“ASI”), subject to prior approval of the Director of Leader & Program Development (TSU-269), on a case-by-case basis. Prior to being authorized for travel and/or being eligible for travel reimbursement, this form must be completed and submitted to TSU-218 with clear copies of the driver’s auto insurance card and driver’s license. Failure to comply with these instructions may jeopardize reimbursement and/or negatively affect future driving privileges. I f renting a vehicle, driver must take full insurance coverage from rental agency.

Name

Student Leaders Driving for leadership position? [ ] Yes [ ] No

Position: Driving for conference? [ ] Yes [ ] No

Club or ICC affiliation Conference details Date(s): City:

Home Address

Telephone No. Home: Cell:

Email Address

California Driver’s License No.

CWID

Car #1 Year, Make, Model

Car #2 Year, Make, Model

Car #1 VIN (not license plate #)

Car #2 VIN (not license plate #)

I have been convicted of a driving-related offense (with the exception of parking tickets) in the last five years. [ ] Yes [ ] No If you answered “Yes,” please explain. You are NOT authorized to drive until you have received notice from the Director of Leader & Program Development in TSU-269. By signing this form and initialing after each of the following points, I attest that I have read, understood and agree to abide by the following:

Whenever I drive on ASI-funded activities, I will have a valid driver’s license and proof of liability insurance in my possession.

If driving my own personal vehicle, I certify that it is in safe mechanical condition and meets all requirements of the California Vehicle Code.

My vehicle is equipped with safety belts in operating condition and my passengers and I will use those safety belts. The use of my private/leased vehicle or a rented vehicle is a consequence of my own choice. I save and hold harmless ASI, the State of California, the Trustees of the CSU, CSU Fullerton, and all of their officers, agents, employees and volunteers against any claim arising out of the use of said vehicle while participating in any program, activity or official business of ASI.

The automobile insurance on the vehicle I am driving meets the minimum requirement as prescribed by California State Law ($15,000 for personal injury to or death of one person; $30,000 for injury to or death of two or more persons in one accident; $5,000 property damage). I understand that my personal automobile liability insurance is the primary coverage if an accident occurs while I am driving my vehicle on ASI-funded activities.

This form authorizes me to drive ONLY one of the the above-listed vehicles. If I choose to drive another vehicle, I must complete another Authorization to Use Privately Owned/Rented Vehicle form prior to my departure.

I understand that ASI prohibits the use of mobile/portable communication devices (cell phone, PDA, BlackBerry, etc.) while driving in connection with an ASI-funded activity – either “hands-free” or otherwise.

I understand that the mileage rate I claim is full reimbursement for the cost of operating the vehicle, including fuel, maintenance, repairs and both liability and comprehensive insurance, and that I am authorized to drive only after receiving approval from the Director of Leader & Program Development on a case-by-case basis.

If an incident/accident should occur while driving in connection with an ASI-funded activity (including any incidental minor damage), I will report same to the Director of Leader & Program Development within 48 hours.

I understand that permission to drive in connection with an ASI-funded activity is a privilege and may be suspended or revoked at any time.

Driver’s Signature: ___________________________________________ Date: ____________________________ Director of L&PD Signature:_________________________________ Date:___________________________ Approved by Exec. Director (or designee): ______________________ Date:___________________________

Executive Senate Travel Request Please provide your contact information and information about the conference or program. Name:

CWID:

Primary Phone:

Email:

Conference/Program: Date(s):

Location:

Please provide a summary of all expenses for travel to this conference or program.

Category Amount

Registration $

Airfare $

Lodging $

Transportation $

Mileage Reimbursement $

Other (please list): $

Total Travel Expenses $

Will you be requesting/receiving funding from a CSUF department? YES NO If yes, please state 1) how much funding is being requested/has been received, 2) the department the funding is being requested/received from, and 3) if the funding has already been approved/the likelihood that it will be approved: The requestor acknowledges that if funding from a CSUF department is received, they will need to submit all original receipts to that CSUF department for reimbursement. The requestor further acknowledges that they will complete all required pre-travel documentation before traveling and will, upon return, submit the required conference report to the council financial officer. _________________________________________________________________________________________________ Student Requestor Signature Date _________________________________________________________________________________________________ Financial Officer Signature Date _________________________________________________________________________________________________ Council Advisor Signature Date

For council use only: Council ______________ Account ______________ Approved Yes ____ No ____ Amount $_________ Date _______

Cover Letter

Paragraph Explaining Why Funding is Needed:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Student Traveler Information:

Name: __________________________________ CWID: _______________________

Address:

Street: ___________________________________________________________

City: _______________________ State: ______ Zip: _________________

Email Address: _____________________________________

Phone Number: _____________________________________

Allocation Request Form

I move that the following allocation be approved:

Program Title:

Sponsor:

Budget Line and Name Amount

807 4 Contracts. Fees and Rentals $

8077 Travel $

Total $

Date. Location andTime:

I understand that I must comply with all fundinE regulations as listed in the funding organization'sbylaws. I understand that at the conclusion of this meeting, it is my responsibility to rneet with theFinancial Officer and complete an Allacatian Dr'spersa/ Forrn and an Encumbrance Form. I

understand that the funds shall not be transferred to my organization's account and that allpayment for goods and services from the monies allocated are to be coordinated with theFinancial Officer no later than two weeks frsm the aforementioned stated program date.

Nanne of Representaiive (Printed) Signature of Representative

Representative's Phone Number Todav's Date

Dispersal Outline

Vendor

Finance Cornmittee Date: Fail Pass Stipulations (on back)

Action Numb.er:General Council Date:

Llndated: 8!7fZA*7