Print and Fill Out the Emergency Contact and Release of Liability Form.

Return the hard copy to the Equipment Room (Cage) in James 348B to keep on file for future field trips.

Participant's Name

First Name

Last Name

Participant's Email

Participant's CBU ID Number

Participant's Cell Phone Number

(###)

###

####

IN CASE OF EMERGENCY

Please provide the contact information for two people that we can contact in case of emergency who do not live at the same address. If your parents live at the same address, please provide both of their names as your #1 Emergency Contact and provide both of their phone numbers. You will need to provide the information of another person for your #2 Contact. If applicable, you may list your spouse as your #1 Emergency Contact, but you will also need to provide information for a #2 Contact.

Emergency Contact #1's Name

First Name

Last Name

Emergency Contact #1's Relationship to Participant

Emergency Contact #1's Cell Phone

(###)

###

####

Emergency Contact #2's Name

First Name

Last Name

Emergency Contact #2's Relationship to Participant

Emergency Contact #2's Cell Phone Number

(###)

###

####

List all allergies (food, medication, etc.):

List prescription medication you are currently taking:

List any other important medical information:

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