Grove City College Athletic Emergency Information

/ Student’s Copy
GROVE CITY COLLEGE SKI & SNOWBOARD CLUB EMERGENCY INFORMATION
NAME: / CLUB: / Ski & Snowboard Club
DATE OF BIRTH: / // / AGE:
HOME ADDRESS:
HOME PHONE: / PARENT’S/GUARDIAN’S NAME:
In case of an emergency, name of parent/guardian to be contacted. Indicate the individual that should be contacted first and indicate the individual who should be contacted second.
1. / Name: / Relation to Student:
Home Phone: / () - / Work Phone: / () -
Cell Phone: / () -
2. / Name: / Relation to Student:
Home Phone: / () - / Work Phone: / () -
Cell Phone: / () -
Date of Last Tetanus Shot: / // / Known Allergies:
Known Medical Condition:
Health Insurance Company: / Policy Number:
Sponsor or Holder of Insurance Policy:
/ Advisor’s Copy
GROVE CITY COLLEGE SKI & SNOWBOARD CLUB EMERGENCY INFORMATION
NAME: / CLUB: / Ski & Snowboard Club
DATE OF BIRTH: / // / AGE:
HOME ADDRESS:
HOME PHONE: / PARENT’S/GUARDIAN’S NAME:
In case of an emergency, name of parent/guardian to be contacted. Indicate the individual that should be contacted first and indicate the individual who should be contacted second.
1. / Name: / Relation to Student:
Home Phone: / () - / Work Phone: / () -
Cell Phone: / () -
2. / Name: / Relation to Student:
Home Phone: / () - / Work Phone: / () -
Cell Phone: / () -
Date of Last Tetanus Shot: / // / Known Allergies:
Known Medical Condition:
Health Insurance Company: / Policy Number:
Sponsor or Holder of Insurance Policy:

Student’s Copy:

Retain this copy and carry it with you on the ski trip and slopes.

Advisor’s Copy:

Return this copy to advisor on boarding the bus, or put into a sealed envelope, and mail to

Matt Jensen

Ski Club Advisor

Box 3146