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Clery Act Student Travel
Group/Department Name
Faculty/Staff Contact
Name
T
itle
D
epartment
Phone
Email
D
eparture from Bradley University
R
eturn to Bradley University
Lodging Facility Information
Note: If group is staying at more than one lodging facility, please complete a separate form for EACH facility.
Name
Address
City
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Postal Code
Sp
ecific floor(s), room number(s), or unit numbers(s) occupied
This trip is
a one-time trip
repeated each semester
repeated annually
other
If other
If repeated, our group
always stays at the exact same lodging facility
uses various lodging facilities with each trip
Person submitting this form
Signature
Date
