EMERGENCY CONTACT FORM Student Field Trip Emergency Information
Class Information
Class Name	Course Number
Instructor	Instructor E-Mail
Semester	Year
Student Information
Student Name
Drivers License Number	State
Expiration Date	Home Phone
In Case of Emergency
Name of Person to Nofity
Relationship	Phone Number
Insurance Information
University of Utah Student Insurance Policy?	Student (or parent/spouse) Own Medical Insurance Policy?
Name of Policy Holder
Name of Insurance Company
Click the button below to submit the form.
If you have any questions regarding the EMERGENCY CONTACT FORM, please contact Sylvia Torti, Entrada Station Manager.