Emergency Information - Confidential Form printable pdf download

EMERGENCY INFORMATION – CONFIDENTIAL

(for use by Department or Waterloo International or Designate only)

STUDENT NAME & ID#:_________________________________________________________________________________

ACADEMIC PROG./DEPT.:______________________________________________________________________________

EMAIL: ________________________________________________________________________________________________

PASSPORT NUMBER & ISSUING COUNTRY: _____________________________________________________________

DEPARTURE DATE: __________________________ RETURN DATE: _________________________________________

HOST UNIVERSITY/EMPLOYER/AGENCY ABROAD: _____________________________________________________

City: ________________________________________ Country: __________________________________________________

ADDRESS IN HOST LOCATION:

________________________________________________________________________________________________________

(Including phone # if known; if not available at this time, provide it as soon as known)

MEDICAL INSURANCE

Are you on the UW Student Supplementary Health Plan? Yes: _____ No: ______

If you are NOT on the uWaterloo Health Plan:

NAME OF OTHER INSURER(S) AND POLICY NUMBER(S):

1,_____________________________________________________________________________________________

2______________________________________________________________________________________________

PERSONAL INFORMATION

Please ensure that your EMERGENCY CONTACT has copies of your personal information including passport, OHIP/UHIP

number, medical/travel insurance coverage, blood type and any information such as allergies, drug sensitivities, regular

medications and other information (e.g., medical condition) that might be of significance to the university, a physician or

hospital treating you in any emergency situation. I have fully informed the Emergency Contact regarding all aspects of my

travel, including the nature of possible risks. Student guarantees that, medical insurance is in force for the duration of the

off-campus program, and in the case of an Emergency, consents to the release of personal information.

_______________________

________________________________________

Date

Signature of Student

EMERGENCY CONTACT

Give the name and address of a designated person who can be reached on your behalf in an emergency.

NAME ____________________________________________ RELATIONSHIP _____________________________________

ADDRESS ______________________________________________________________________________________________

PHONE Home __________________________ Cell __________________________ Business __________________________

Fax ____________________________ Email ___________________________________________________________

STUDENT SHALL RETAIN COPY UNTIL THEY RETURN TO CAMPUS AND IS RESPONSIBLE FOR RETURNING SIGNED FORM PRIOR

TO DEPARTURE TO THEIR ADVISOR AND (FOR INTERNATIONAL LOCATIONS) TO WATERLOO INTERNATIONAL, NEEDLES HALL

1101 fax: 519-888-4355

Emergency Information - Confidential Form