Emergency Information
Click HERE for a hard copy of the form.
NAME OF STUDENT PARTICIPANT
In Case Of Emergency, Contact
At The Following Number
Health Insurance Company Name
Policy Number
Medical Conditions/Food Allergies to Note
Please list any special services you may require due to an existing medical condition or physical disability: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Vehicle
Insurance Information
Automobile Insurance Company Name
Policy Number
Policy Limits
UWSP
Protective Services (715)
346-3456
UWSP
Transportation Office (715)
346-2884
Student
Involvement and Employment Office (715)
346-4700
Your Advisor’s Number
Trip Leader’s Number
Cell Phone Number on Trip
Other Numbers:
(It is recommended that
copies are given to: 1 copy for trip leader’s file, 1 copy for advisor’s file
and 1 for the participant)