The University of Southern Mississippi
Gulf Coast Research Laboratory
Field Trip Program

Dormitory Registration

Occupancy Dates
From

To

Name

Address

Affiliated With

Dormitory Rates Per Person*

Affiliate Institute Daily Rate $15.00
Non-Affiliated Institute $20.00
Bed Linen & Towels (per week)** $5.00
Lost Key Charge $10.00

Total Amount


In case of accident notify:

Name

Address

Telephone(s)


Release From Liability For Death Or Bodily Injury Occurring While Pursuing Academic Study At The Gulf Coast Research Laboratory

In consideration for being offered the opportunity to pursue academic study at the Gulf Coast Research Laboratory, I the undersigned do hereby waive for myself and for my estate any rights to claims for damages, incident to death or any bodily injuries whatsoever that may result during the period of study, including activities on board any boat belonging to said Laboratory, or during any off-campus field trip which is a part of required study. This waiver of damages for death or bodily injury shall apply like wise to any minor child (under 21 years of age) for whom I have legal responsibility.

This instrument releases the State of Mississippi, the Gulf Coast Research Laboratory, and any employee of the State or of the Laboratory from liability for death or bodily injury to the undersigned or to minors for whom I am legally responsible, occurring under the circumstances as described above.

I have read the above instrument and fully understand its intent.

Signature

Date

 
Witnessed Date

*Rates are subject to change without notice.

**Linens will be issued at the beginning of stay and will be reissued on a weekly basis. An additional fee will be charged for extra linens.