SSC EMERGENCY CONTACT FORM - SPRING 2026

Form fields marked with an asterisk (*) are required.

EMERGENCY CONTACT FORM

STUDENT TRAVEL EMERGENCY TREATMENT INFORMATION

NOTE: The information you share will be kept confidential and will be provided to emergency/hospital personnel only in the event of an emergency.

NAME OF EVENT AND/OR ACTIVITY THIS FORM IS BEING COMPLETED FOR:

EVENT DATE:

FACULTY AND/OR STAFF MEMBER OVERSEEING THE EVENT:

SSC DEPARTMENT AND/OR ORGANIZATION OVERSEEING THE EVENT:

LAST NAME:

FIRST NAME:

MySSC Student ID #

Medical Conditions (if none, write "N/A"):

Allergies (food, medications, etc. – if none, write "N/A"):

Current Medications and Dosage/Frequency (if none, write "N/A"):

In case of emergency, please provide the name of two emergency contacts below:

Contact Name #1 (first and last):

Contact #1 Cell Phone Number:

Contact #1 Address (include street, city and state):

Contact Name #2 (first and last):

Contact #2 Cell Phone Number:

Contact #2 Address (include street, city and state):

Permission for Emergency Treatment

Required

I hereby authorize Seminole State College to obtain emergency medical treatment for me in the event that I am unable to give consent to such treatment in order to protect and preserve my health and well-being.

COVID-19 Statement

Required

I understand that if I test positive for COVID or am having symptoms before the program, I will not attend. If I demonstrate COVID symptoms or test positive for COVID while at the program, there may be additional costs associated with health concerns or the need to quarantine.

By providing this information and signing below, I authorize Student Life staff to use and appropriately share this information with medical personnel to provide for my medical care and treatment.

NAME:

DATE (MM/DD/YY):