Belmont Group Travel Registration Form

Belmont Group Travel Registration Form

One form per travel group to be submitted by Faculty/Staff leader. All travelers within the group will submit the Belmont Traveler Registration Form
Outwith Terra Dotta
Form being completed by:*

First NameLast Name
Your Belmont email*
Belmont email address
Program Leader Information
Full Name of Program Leader:*

First NameLast Name
Program Leader Email:*
Belmont Email Only
Program Leader BUID:*
Program Leader Role at Belmont:*

FacultyStaffOther: please describe
Program Leader College/Department of Employment*
Select the College or Department where you work/teach/study (Ex.someone employed by the College of Medicine traveling on a Belmont Mission trip would select College of Medicine in this box).
Please List Program Leader's College/Department of Employment:*
You have selected "Other Staff: office/department not listed above" in the previous question.
Travel Information
Please list the person or office who has approved your travel:*
Approver Name
Approver Email Address*
Approver Belmont Email

Location(s) of travel for the approved Belmont trip*

	City	Country
Location 1
Location 2
Location 3
Location 4
Location 5

Check the current travel advisory status of the locations you are visiting:

U.S. Department of State - Travel Advisories
Are any of the locations a level 3 or 4 travel advisory?*

NoYes
Travel to any level 3 or 4 countries is required to be reviewed by the Belmont International Risk Management Committee for approval*

I acknowledge that my travel will be reviewed by the International Risk Management Committee for approval
Please explain the reasoning for traveling to a country that is currently ranked as a Level 3 (Reconsider Travel) or Level 4 (Do Not Travel)*
Please explain what steps you will take to best prepare students prior to travel and what actions will be taken to ensure the safety and security of the group while traveling in a high-risk location.*
Cities and Countries of Travel:
Please use city, country format. Multiple entries sperated by "&"
Departure Date (leave Belmont/Home)*

MonthDayYear
Group Travel Begins
Return Date (return to Belmont/Home)*

MonthDayYear
Group Travel Ends
Number of Days for Belmont Travel*
Please do not include any personal travel or vacation time
Are students traveling with the group?*

YesNo
Anticipated Number of Students Traveling*
Anticipated Number of Faculty/Staff Traveling*
Anticipated Number of Others (not listed above) Traveling*
Please list the names of all travelers in this group*
I agree that the organization/college/department organizing this trip is responsible for ensuring all participants register their travel on the Belmont Traveler Registration Form (linked below)*

I agree
I understand that any traveler who fails to submit the Belmont Traveler Registration Form (not including Study Abroad, Global Honors, or Belmont on Mission participants) will not be enrolled with Belmont's international medical insurance.*

I understand
All travelers need to submit the Belmont Traveler Registration Form to officially register their travel with the Office of Risk Management & Compliance
International Medical Insurance and Risk Management Support

Anyone traveling with or on behalf of Belmont University will need to have international medical insurance and access to Belmont's crisis management service.
Does your group need to purchase Belmont's approved international medical insurance?*

Yes, each traveler will purchase their own insurance through the Belmont Traveler Registration FormYes, the organization/college/department responsible for organizing the trip will pay for all participants' insuranceNo/Other (please explain)
Risk Management Support Fee*

Each traveler will pay the risk management support fee on the Belmont Traveler Registration FormThe organization/college/department responsible for organizing the trip will pay for all participants' risk management support fee
On Campus-Belmont Emergency Contact Information

Each group needs one on-campus faculty/staff member willing to help coordinate in the event of a group emergency. This person should not be traveling with the group.
Belmont Emergency Contact*

First NameLast Name
Belmont Emergency Contact Number:*
Should be Empty:

Belmont Group Travel Registration Form

Outwith Terra Dotta

Program Leader Information

Travel Information

All travelers need to submit the Belmont Traveler Registration Form to officially register their travel with the Office of Risk Management & Compliance

International Medical Insurance and Risk Management Support

On Campus-Belmont Emergency Contact Information