Cross Cultural Retreat 2017 September 22-24, 2017
Cross Cultural Retreat CSUDH Cross Cultural Retreat September 22-24, 2017 What is the Cross Cultural Retreat? Fun, new-found friendships, awareness, and the celebration of difference await you at the Annual Cross Cultural Retreat! The year s retreat will take place on September 22-24 2017. The Cross Cultural Retreat provides an opportunity for honest dialogue about issues related to diversity and how to build effective multicultural alliances across cultures. At the Cross Cultural Retreat, students, faculty and staff will experience thought-provoking workshops and small group discussions about cross cultural issues while striving toward building community. *Please note the committee will review all applications to ensure a diverse pool of applicants is represented. *Due to a limited number of spaces, not all applicants may have a chance to attend. Location/Accommodations: This year s retreat will be held at the American Jewish University, Brandeis-Bardin Campus in Simi Valley, CA. Students will be pre-assigned to rooms. If any participants require specific needs such as mobility assistance, hearing interpreters, seeing assistance, or other types of assistance, please call the MCA at (310) 243-2519 to make the proper arrangements. Registration Priority: Cal State Dominguez Hills participants (students, staff, faculty and administration) must apply to attend the retreat. Deadline to submit application and registration deposit is Friday, September 15, 2017 by 5 PM. Take your registration form and payment to Multicultural Affairs, Loker Student Union #110. Due to the nature of the retreat, you must attend the ENTIRE program. Deposit Payment Information: Since seats are limited, a one-time $20 deposit is required to confirm your reservation. The fee deposit will be returned at the end of the retreat provided that you attend the full program. Cross Cultural Retreat is open only to members of the Cal State Dominguez Hills community; faculty, administrators, staff, and registered students only. Students may not bring guests to the site. *The deposit will be forfeited if MCA, is not notified of any cancelation five days prior to the event. Transportation/Arrival & Departure Time: The bus leaves at 1pm on Friday, September, 22 from the flag pole by the Small College Complex (SCC). Program begins at 4:30pm on Friday and ends at 2pm on Sunday, September 24. You may not leave the retreat site at any time. All students are requires to take the charter buses to the retreat. Students may not drive their own vehicles to the retreat. The Multicultural Affairs is a service of the Division of Student Affairs. For more information please contact us at (310) 243-2519. mca@csudh.edu or at www.csudh.edu/mcc
Registration Form Name Address City State Zip Code Phone Second Phone Email Address Ethnic Origin Gender Student Class Standing Freshman Sophomore Junior Senior Graduate Have you attended the Cross Cultural Retreat before? yes no Are you a vegetarian or have specific dietary restrictions? yes no Please specify dietary restrictions: Do you need any assistance with physical accommodations? If so, please call the MCA office. Personal Vehicle Information Make Model What year have you attend CCR? Year Color My Vehicle has a current CSUDH parking permit for Fall 2017 semester I plan to leave my vehicle at CSUDH. YES NO I understand that leaving my car on campus for the duration of the retreat requires a valid parking permit for those days. All vehicles will be monitored by campus police for the duration of the retreat. T Shirt Size small M L XL Emergency contact information Name Address City State Zip Code Phone Second Phone Payment Information CSUDH Student Faculty Staff Administrator A one-time $20 deposit is required to insure your participation at the retreat. The fee deposit includes assurances for participation in all retreat activities, lodging, 2 nights & 5 meals. Deadline to submit application and registration deposit is Friday, September 15, 2017 by 5:00 pm. Please make checks payable to the CSUDH Multicultural Affairs. Please take the payment and registration form to Multicultural Affairs, Loker Student Union #110. All student participants will have pre-assigned rooms and roommates. A full refund of your deposit will be returned when: You attend and participate in all activities at the retreat, or You cancel no later than 4 days prior to the event (9/18/17) by 5 PM, or after discussion with the Coordinator of the MCA ***FAILURE TO ABIDE BY THESE CONDITIONS WILL RESULT IN THE FORFEITURE OF YOUR DEPOSIT. Total attached: $ Activity Release I, the undersigned, hereby agree that, in consideration for being permitted by the California State University, Dominguez Hills to participate in the Cross Cultural Retreat scheduled for September 22-24, 2017, I will indemnify, hold harmless and release the State of California, the Trustees of the California State University, California State University Dominguez Hills and their officers, employees and agents, the Multicultural Affairs, and the Associated Students, Inc. from all claims, demands or causes of action which I may have by reason of any accident, illness, injury, death or other consequence arising or resulting directly or indirectly from my participation in this activity. I agree to sign any additional waivers associated with attending this retreat. 2XL Other Participant Signature Parent Signature (if under 18 years old)
University Communications and Public Affairs 1000 East Victoria Street, Carson, CA 90747 310-243-2001 / Fax 310-516-3976 www.csudh.edu Visual/Audio Image Release Form I grant permission to California State University, Dominguez Hills (CSUDH), its employees and agents, to take and use visual/audio images of me. Visual/audio images are any type of recording, including but not limited to photographs, digital images, drawings, renderings, voices, sounds, video recordings, audio clips or accompanying written descriptions. CSUDH will not materially alter the original images. I agree that CSUDH owns the images and all rights related to them. The images may be used in any manner or media without notifying me, such as university-sponsored web sites, publications, promotions, broadcasts, advertisements, posters and theater slides, as well as for non-university uses. I waive any right to inspect or approve the finished images or any printed or electronic matter that may be used with them, or to be compensated for them. I release CSUDH and its employees and agents, including any firm authorized to publish and/or distribute a finished product containing the images, from any claims, damages or liability which I may ever have in connection with the taking of use of the images or printed material used with the images. I am at least 18 years of age and competent to sign this release. I have read this release before signing, I understand its contents, meaning and impact, and I freely accept the terms. Name (please print) Signature Telephone or E-mail address Signature of parent or guardian if under 18 years of age Address (optional) Project Name Cross Cultural Retreat Fall 2017
RELEASE OF LIABILITY, PROMISE NOT TO SUE, ASSUMPTION OF RISK AND AGREEMENT TO PAY CLAIMS Activity: Activity (s) and Time(s): CCR is a 3 day-2 night retreat. The retreat involves travel to the site & return to CSUDH. The activities include travel, overnight accomodations, workshops, icebreakers, and meals. Risk includes but not limmited to terrain, temperature, equipment, and travel. Friday, September 22nd, 2017 at 11 AM to Sunday, September 24th, 2017 at 5 PM (approximately) Activity Location(s): Round trip CSUDH traveling by bus to American Jewish University (retreat site) in Simi-Valley. In consideration for being allowed to participate in this Activity, on behalf of myself and my next of kin, heirs and representatives, I release from all liability and promise not to sue the State of California, the Trustees of The California State University, California State University, Dominguez Hills and their employees, officers, directors, volunteers and agents (collectively University ) from any and all claims, including claims of the University s negligence, resulting in any physical or psychological injury (including paralysis and death), illness, damages, or economic or emotional loss I may suffer because of my participation in this Activity, including travel to, from and during the Activity. I am voluntarily participating in this Activity. I am aware of the risks associated with traveling to/from and participating in this Activity, which include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability (including paralysis), economic or emotional loss, and/or death. I understand that these injuries or outcomes may arise from my own or other s actions, inaction, or negligence; conditions related to travel; or the condition of the Activity location(s). Nonetheless, I assume all related risks, both known or unknown to me, of my participation in this Activity, including travel to, from and during the Activity. I agree to hold the University harmless from any and all claims, including attorney s fees or damage to my personal property, that may occur as a result of my participation in this Activity, including travel to, from and during the Activity. If the University incurs any of these types of expenses, I agree to reimburse the University. If I need medical treatment, I agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance. I am 18 years or older. I understand the legal consequences of signing this document, including (a) releasing the University from all liability, (b) promising not to sue the University, (c) and assuming all risks of participating in this Activity, including travel to, from and during the Activity. I understand that this document is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I have read this document, and I am signing it freely. No other representations concerning the legal effect of this document have been made to me. Participant's Signature: Participant's Name (Print): :