Clery Act Student Travel Form

This form is to be completed for any College-related overnight travel that includes students such as athletics, academics, clubs/organizations, etc. The form is also available in print-format at www.uvawise.edu/compliance. **NOTE: Please submit the form AFTER your travel to ensure you have complete information, including specific rooms/suites occupied.** If you have questions, please contact Tabitha Smith in the Office of Compliance & Inclusion at 276-328-0131 or tsh5d@uvawise.edu.

Today's date *

Month

Day

Year

Name of person submitting this form *

Group Name *

TRAVEL CONTACT INFORMATION

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

Name *

Title *

Department *

Phone *

UVA Wise Email *

TRAVEL DATES

Check-in Date *

Month

Day

Year

Check-Out Date *

Month

Day

Year

LODGING FACILITY INFORMATION

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

Name *

Address *

Specific floor(s), room number(s), or unit number(s) occupied *

This trip is *

a one-time trip

repeated each semester

repeated annually

other*

*If you selected "other" above, please explain

If trip is repeated, our group

always stays at the exact same lodging facility

uses various lodging facilities with each trip

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