Fillable Emergency Contact Form 1.21.16 Fillable CSU, Chico Emergency Contact & Medical Information

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Emergency Contact Form 1.21.16 Fillable CSU, Chico Emergency Contact & Medical Information

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California State University, Fresno
Off-Campus Event, Form 3
CSU Executive Order 1062
ACADEMIC OFF-CAMPUS EVENT EMERGENCY INFORMATION FORM
Participant’s Name Date of Birth ____________
Last First MI
Emergency Contact Information (required)
Emergency Contact #1 must be able to make legal decisions for you in a worst-case scenario.
Emergency Contact 1
Emergency Contact 2
Last, First Name
Relationship
Street Address
City, State, Zip, Country
Phone: Home
Phone: Work
Phone: Cell
Medical Information (optional)
Hospital/Clinic Preference ___________________________________________________________
Medical Insurance Company _________________________________________________________
Policy/Group Number ______________________________________________________________
Phone Number____________________________________________________________________
Do you have any allergic reactions to bee/insect stings, medications, food/drink, etc.?
If yes, please explain and note associated reaction(s) below:
___________________________________________________________________________________________
___________________________________________________________________________________________
Do you have any medical information that may be pertinent to your emergency care (such as: pre-existing
conditions or essential medications)?
If yes, please explain below:
___________________________________________________________________________________________
___________________________________________________________________________________________
PLEASE NOTE
Completing the medical information section of this form is voluntary. It will be referred to ONLY in case of a
critical injury or emergency situation. In the instance that you are unable to provide medical information to an
attending physician or hospital, we would be able to provide it for you with your consent by signing below.
_________________________________________________ ___________________________
Signature Date
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Emergency Contact Form 1.21.16 Fillable CSU, Chico Emergency Contact & Medical Information

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Completed 9 April 2020

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