EMERGENCY CONTACT: Emergency contact name: ________________________________________________________ Relationship to student: _________________________________________________________ Home phone:________________________ Cell/Alternate phone: ________________________ PHYSICIAN AND INSURANCE: Physician’s Name: _______________________________________________________________ Phone:________________________________________________________________________ Insurance Provider: _____________________________________________________________ Insurance Contact Phone No.: _____________________________________________________ Group No.: ____________________________________________________________________ Name of Covered Member: _______________________________________________________ I, ___________________________________________________, warrant that to the best of my knowledge I am able to participate in travel with the Community College of Allegheny County (CCAC) Honors Program. In the event of circumstances that require immediate medical care, I hereby give authorization to CCAC, its faculty, representatives and agents to seek and provide medical services for me when deemed appropriate by CCAC staff, including transportation to a hospital, clinic, or medical facility, for evaluation and emergency medical or surgical treatment. I authorize any physician, nurse, or staff member at such medical facility to share personal information with CCAC staff or representatives to the extent such a disclosure is necessary to properly treat me. I also give authorization to CCAC representatives to share information with other CCAC agents on a need-to-know basis. I assume all risks, known and unknown, foreseeable and unforeseeable, in any way connected with my participation in the travel program. I have read and understand this document and understand its significance, and have executed this document voluntarily and truthfully.
Signature and Date: ____________________________________________________________
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