MONTCLAIR STATE UNIVERSITY

GLOBAL EDUCATION CENTER

Office of International Studies

Upper Montclair, NJ 07043

EMERGENCY TREATMENT PERMISSION AND CONTACT

On rare occasion, an emergency requiring hospitalization and/or surgery may develop. This form is a safeguard to prevent dangerous delay in case of emergency.

THIS INFORMATION IS FOR: (Student's Name)

1. Emergency Contacts:

Name Relation

Address City, State, Zip

Day Phone( ) Evening Phone

2. I am insured under:

Policy number Company name

Expiration date

3. Medicines I am allergic to:

4. The following are medical conditions in which a physician in another country should be made aware of:

5. In the event of an emergency and we cannot be reached, we give our consent to authorize a representative of the host institution to authorize treatment or hospital care which in the best judgement of a licensed physician is deemed advisable.

Signature of Student Date

Signature of Parent Date or legal guardian (if applicable)

NOTE: Make at least three (3) copies of this form:

1 for self, put inside passport

1 for file in Office of International Studies

1 for host institution