ࡱ> .0-y bjbj .{{ V0((((($8v(( (((Pa4 &0V#j4V : Instructions and Information in Case of an Emergency The University of 91ȫܰ The information submitted is confidential and will only be used by your professor/instructor to respond to emergency situations. For safety, and to aid in response to any emergency that may arise, information will be provided to the Government of Canada through its Department of Foreign Affairs and International Trade. Name of Course: ____________________________________________________________________ Full Name: ___________________________________ Student Number: _______________ Permanent Address: ___________________________________________________________________ Passport Number: __________________________ Date of Birth: ___________________ Nationality: ________________________________ Issuing Authority: ________________ Passport Expiry Date: ________________________ Health Insurance (provider and policy number) Provincial Health Insurance: ____________________________________________________________ Supplemental Health Insurance: _________________________________________________________ Family Doctor Name: ___________________________________ Phone Number: __________________ Address: _____________________________________________________________________________ Allergies and/or Dietary Restrictions: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Note: If you have dietary restrictions or allergies relevant to your participation in the course, we strongly recommend you discuss them with your course instructor prior to departure. Other Health Concerns: Please list any medical conditions or medications you take daily, regularly, or on an as needed basis that are relevant to your participation in this course. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Note: Participants must bring an adequate supply of medications that are required on a daily or routine basis when travelling. If you have a medical condition which may be relevant to your participation in the course, we strongly recommend you discuss it with your course instructor prior to departure. Emergency Contact Information Emergency Contact # 1 Name: ___________________________________ Relationship to student: _________________ Phone Number: ___________________________ Email: _______________________________ Emergency Contact # 2 Name: ___________________________________ Relationship to student: _________________ Phone Number: ___________________________ Email: _______________________________ Signature Date __________________________________________ _____________________________________ 5Qkm  9 : C r  ' l 4 = E \ ]isyŽŵŽţͭɒ͋ɭ hohohoho5\ hG}hG}hG}hG}5\hohG}5hoho5hoh35h3hG}hohE=$h-Th-TCJOJQJaJnH tH h>t h-Th-Th-Thoh-T56Q : m ' 3 4 i3gdG}gdogd-T$a$gdo(_`aho hG}hG}hG}h>t `agd-TgdG},1h/ =!"#$% j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH J`J Normal dCJ_HaJmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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