EmailMe Form - Clery Act Student Travel Form

Today's Date

MM / DD / YYYY

Travel Contact Information

I understand that I am a Campus Security Authority (CSA) for this trip and must report to Campus Safety in a timely manner any crimes brought to my attention.

Name

First Last

Title

Department

Phone

### - ### - ####

College Email

Travel Dates

List dates of the college-sponsored student travel below.

Check-In Date

MM / DD / YYYY

Check-Out Date

MM / DD / YYYY

Lodging Facility Information

Note: If group is staying at more than one lodging facility, please complete a separate form for EACH facility.

Facility Name

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

List specific floor(s), room number(s),or unit number(s) occupied:

Additional Trip Information

This trip is (select one):

A one-time trip

Repeated each quarter

Repeated annually

Other

If this trip is repeated, our group:

Always stays at the exact same lodging facility

Uses various lodging facilities with each trip

Please select one:

To the best of my knowledge, no crime was committed in this place of lodging during the dates of our stay.

During the time period of our stay, a crime was reported at this place of lodging. (Please describe the crime in the box below.)

Description of Crime

Please include as much detail as possible regarding the crime, to include date and time of crime, type of crime, whether or not victim is student or non-student of Centralia College.

Signature

Clear