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2026-27 Emergency Data Form
This form is good for the season, but please update/resubmit or contact trips@unrecables.org if your information changes
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* Indicates required question
Name
*
Your answer
Medications / Special Circumstances
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Phone
*
Your answer
Physician’s Name
*
Your answer
Physician’s Phone
*
Your answer
Do you have health/medical insurance?
*
Yes
No
If you have health/medical insurance, which company?
("None" if you do not have health insurance)
*
Your answer
Policy/ID Number
("None" if you do not have health insurance)
*
Your answer
Group ID or Contract Code
("None" if you do not have health insurance)
*
Your answer
Insurance Phone
("None" if you do not have health insurance)
*
Your answer
What other important things do we need to know about you in case of emergency? (allergies, etc.)
Your answer
Additional suggestions
Your answer
I hereby acknowledge that the information provided above is true and accurate. If any of the above information changes, I will inform the Winter Trip Director
(email trips@unrecables.org , call or text 858-208-6088) to update the information.
*
I Acknowledge
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