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 Name
Last Name
Your Belmont email
*
Belmont email address
Program Leader Information
Full Name of Program Leader:
*
First Name
Last Name
Program Leader Email:
*
Belmont Email Only
Program Leader BUID:
*
Program Leader Role at Belmont:
*
Faculty
Staff
Other: please describe
Program Leader College/Department of Employment
*
Please Select
College of Architecture and Design
College of Art
College of Business
College of Entertainment and Music Business
College of Education
College of Liberal Arts and Social Sciences
College of Medicine
College of Music and Performing Arts
College of Nursing
College of Pharmacy and Health Sciences
College of Sciences and Mathematics
Interdisciplinary Studies and Global Education
Office of the President
Office of the Provost
Belmont on Mission Trips
Office of Study Abroad
Other Staff: office/department not listed above
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:
*
Please list name and email
Location(s) of travel for the approved Belmont trip
*
City
Country
Location 1
Location 2
Location 3
Location 4
Location 5
Cities and Countries of Travel:
Please use city, country format. Multiple entries sperated by "&"
Departure Date (leave Belmont/Home)
*
/
Month
/
Day
Year
Group Travel Begins
Return Date (return to Belmont/Home)
*
/
Month
/
Day
Year
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?
*
Yes
No
Anticipated Number of Students Traveling
*
Anticipated Number of Faculty/Staff Traveling
*
Anticipated Number of Others (not listed above) Traveling
*
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.
*
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
Belmont Traveler Registration Form
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 Form
Yes, the organization/college/department responsible for organizing the trip will pay for all participants' insurance
No/Other (please explain)
Risk Management Support Fee
*
Each traveler will pay the risk management support fee on the Belmont Traveler Registration Form
The 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 Name
Last Name
Belmont Emergency Contact Number:
*
Submit
Should be Empty: