Emergency Contact And Information Form

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EMERGENCY CONTACT and INFORMATION FORM
Please Print!
Name
______________________________________________________________________
Date of Birth ______________________
Sport___________________________________
SNHU ID#
______________________
Academic Year
2009-2010
The Acknowledgement of Insurance Requirements must be read and this form completed
Prior to the student-athlete participating in practice and/or competition
Parent/Guardian Name _________________________________________________________________
Address
_______________________________________________________________________
_______________________________________________________________________
Home Phone _________________________
Work Phone _______________________________
Policy Holder Name ____________________Relationship to Student-athlete _____________________
Address
_____________________________ Home Phone _______________________________
_____________________________ Work Phone _______________________________
Insurance Company Name
____________________________________________________________
Insurance Company Address ____________________________________________________________
Group #
____________________________ I.D. # ____________________________________
Effective Date of Policy
____/____/____
Expiration Date ____/____/____
Primary Physician
_________________________________________________________________
Office Number
___________________________________________________________
Policy Limit
__________________
Policy Deductible __________________________
Policy Co-Pay
_________________________________________________________________
Does the policy cover athletically related injuries? ___________________________________________
I have read and agree to comply with the provisions of the Acknowledgement of Insurance
Requirements.
___________________________________
_____________________
Student-Athlete Signature
Date
This form must be completed prior to first day of practice.
Return to:
Jaime Browne
Compliance Coordinator
Southern New Hampshire University
2500 North River Road
Manchester, NH 03106-1045
j.browne @snhu.edu

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