Field trip/work and emergency contact form

Course(s):

ENVS 200

Student Information

Student ID Number:

First Name:

Last Name:

UWaterloo Email:

Phone Number:

Medical Insurance

Do you have a student supplementary health plan?

Yes

Other Policy:

If "No", list your insurer(s) and policy numbers.

Emergency Contact Information

Please ensure that your emergency contact has copies of your personal information including OHIP/UHIP number, medical/travel insurance coverage, blood type and any information such as allergies, drug sensitivities, regular medications and other information (e.g., medical condition) that might be of significance to the university, a physician or hospital treating you in any emergency situation. I have fully informed the emergency contact regarding all aspects of my travel, including the nature of possible risks. Student guarantees that medical insurance is in force for the duration of the off-campus program and in the case of emergency, consents to the release of personal information.

I have informed my emergency contact:

Yes

First Name:

Last Name:

Relationship:

Primary Phone Number:

Business Phone Number:

Contact Email:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Disclaimer

I recognize that I will be involved in one or more field trips or field work as part of my being a registered student of the course indicated above.

I am aware that participation in any such field trips or field work includes a variety of risks, hazards and conditions, including but not limited to personal injury, death, property damage or other loss, of any nature whatsoever and howsoever caused, resulting from, arising in connection with or otherwise related to the above-mentioned field trip or field work activities. Conditions may include, but are not limited to, travelling and commuting, uneven terrain, changeable weather conditions including heat, cold and wetness, animal and plant life, exposure to laboratory chemicals and lab equipment that may have hot surfaces.

I acknowledge that:

I have read the Field Trip and Field Work Guidelines of the Faculty of Environment;
I have had the opportunity of asking further questions of my instructor;
I am expected to abide by the policies, procedures and practices of the university/agency/location where I am studying or working; as such, I will respect the policies of the University, in particular with regard to Student Discipline and Ethical Behaviour;
I am solely responsible for all expenses (accommodation, phone/fax/email) relating to my stay at the at the university/agency/location, unless otherwise arranged;
I have informed my designated emergency contact (as per the attached Emergency Information Form) regarding all aspects of this program, including the nature of possible risks.

I understand that the University is not responsible for any death, injury, loss or damage of any kind suffered by myself or any other person while participating in any of the above-mentioned activities and I agree to waive any and all claims and/or actions against the University and any of its governors, officers, employees and other representatives. All University students must be covered by a provincial health care plan, UHIP or an approved equivalent plan to UHIP. This provides coverage for physician and hospital expenses up to the varied maxima of these plans.

I am aware of, freely accept and fully assume all above-mentioned risks, hazards and conditions. I further acknowledge that the University cannot guarantee my health or safety. I voluntarily agree to participate in the above-mentioned activities.

I have read, understand and agree to the information provided on the field trip/work and emergency contact form.

I agree:

Yes

Date:

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