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College at Brockport Student Trips to Off-Campus Locations: Clery Annual Security Report Form

Please complete a separate form for each trip that is included in the Annual Clery Security Report within 30 days following the trip.

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  • Select one: (Clery definitions are on the next page) *
    Select one: (Clery definitions are on the next page)
  • Lodging Address Lodging Address *
  • Check-in Date: Check-in Date: * / /
    Pick a date.
  • Check-in Time: Check-in Time: * :
  • Check-out Date Check-out Date * / /
    Pick a date.
  • Check-out Time: Check-out Time: * :
  • Law Enforcement Agency Address Law Enforcement Agency Address *
  • Contact Contact *
  • Contact's Phone Number Contact's Phone Number * - -
  • Additional information required for "short-stay away trip" and Clery definitions next page.

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