HEALTH AND EMERGENCY
INFORMATION
Name__________________________________________________________
Program________________________________________________________
The purpose
of this form is to provide information should an emergency arise during your
travel off the UWL campus. The information will remain confidential and will be
shared with program staff, faculty, or appropriate professionals only as
necessary.
Provide information on any medical condition for which you are currently being treated:
Provide any additional medical information (e.g., allergies, prescriptions, dietary restrictions, etc.):
Emergency Contacts:
In
the case of an emergency, I authorize the UW-La Crosse Department of Music to
contact the following contact persons:
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This is to certify that I will be covered by a health and accident insurance policy for the duration of my travel as a participant in the above-named program. This insurance is provided through:
Insurance Company____________________________________________________
Policy Number________________________________________________________
Signature of Participant Date
Signature of Parent/Guardian Date
(required if participant is under 18 years of age)