California State University, Fresno
Off-Campus Event Policy, Form 3
ACADEMIC OFF-CAMPUS EVENT EMERGENCY INFORMATION FORM
Participant’s Name SS#
Last First MI
Home Address
Telephone Age Birthdate ____________________
EMERGENCY CONTACT(S) (Names and Phone Numbers)
Name
Address
Relationship
Home Phone # Work Phone #
Name Address
Relationship Home Phone # Work Phone #
Personal Physician’s Name
Address Phone#
I am presently under the following medication
I am allergic to the following medication
Presently wear contact lenses? Presently wear glasses?
Please
state
any
medical
conditions
that
emergency
care
providers
need
to
be
aware
of
Do you have health insurance?
Policy #
Name of Insured (if different from self)
Relationship
Name of Company
Telephone #
Address of Company
If I need medical treatment arising out of my participation in this activity, I give my consent for
the university to release the information on this form to any medical professional.
Signed Date
Signature of participant, or parent or legal guardian, if participant is a minor.
Copy distribution: Event Leader
Rev 04/05/06
