Contact Information for Research Field Trips
In the event of an emergency while on a geology class field trip, please provide the following information
Faculty Advisor *
Your answer
Dates of Field Trip *
Your answer
Destination(s) and Purpose of Trip: *
Your answer
Name *
Your answer
I am a: *
Campus Address *
Your answer
Phone number *
Your answer
Email *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Address *
Your answer
Contact Phone *
Your answer
Contact Email *
Your answer
Please provide the name of your medical insurance carrier and a policy number below
Insurance Carrier: *
Your answer
Policy Number: *
Your answer
If you have a special health condition that an attending physician must know of in the case of an emergency, please provide the information in a sealed envelope to the supervising faculty member of your field trip. The faculty member will keep the sealed envelope until the trip is over and then return it back to you.
In case of an emergency contact Caltech Security at 626-395-4701 , or extension 5000 from campus phones.
GPS Contact People
Aleen Boladian: 626-395-6206
John Grotzinger: 626-395-6108
Rob Clayton: 626-395-6909
Jen Shechet: 626-395-6111

Please print a copy for your records , then click the "Submit" button below to submit this form electronically. Alternately, you can use campus mail to send the form to: Mark Garcia MC 170-25

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