Emergency Information for Domestic Trips
Original is retained in the department and a copy is kept with the Trip Sponsor while on the trip.
Trip Sponsor:
Trip Destination:
Trip Dates:
For domestic travels it is necessary that we collect emergency contact information and health
insurance information from all students going on a University-sponsored trip. Please clearly complete
the following information and return it to the Trip Sponsor.
STUDENT NAME: (please print clearly)_________________________
Z NUMBER: ______________________
CONTACT INFORMATION FOR STUDENT:
Your cell phone _________________________ Your email ____________________________
IMPORTANT PERSONAL INFORMATION (allergies, illnesses or conditions we need to be aware of,
etc.):
EMERGENCY CONTACT INFORMATION:
Emergency Contact (MUST BE SOMEONE NOT GOING ON TRIP WITH YOU)
NAME _________________ _____ PHONE_________________________
Secondary Emergency Contact (MUST BE SOMEONE NOT GOING ON TRIP WITH YOU)
NAME ______________ ________ PHONE_________________________
INSURANCE INFORMATION:
Company:
Policy/Group numbers:
Phone Number:
Other relevant information: (e.g., name of insurance holder if not yourself):
