ࡱ> O bjbjUU 0T7׎e7׎eH H \*|5555T,)))))))$,/v)...)55)JJJ.55)J.)JJ(B)5p>D (r))0*(0N0,B)0B)0..J.....))J...*....0.........H S:  FORM 3 Emergency Notification Information Each traveler must complete this form Fill or mark through all blank spaces Full Name  Preferred Name  Student ID #  Date of Birth  Age  FORMCHECKBOX  FORMCHECKBOX MaleFemale Address  Cell Phone #  City  State  Zip  Email  Status: FORMCHECKBOX FR FORMCHECKBOX SO FORMCHECKBOX JR FORMCHECKBOX SR FORMCHECKBOX Grad FORMCHECKBOX Faculty FORMCHECKBOX Staff Medical conditions we should know about Drug Allergies  Medications you are currently taking (prescription and non-prescription)  Physicians Name:  Phone #:  Insurance Company:  Policy #:  Name of Policy Holder:  Group#:  Employer:  I hereby authorize Texas A&M University-Kingsville to release information pertaining to myself in the event of an emergency. This information will be made available on a need to know basis to organizational officers and advisor(s), the Dean of Students, key administrative staff, the University Police Department and other external hospital and emergency response officials. Signature of TravelerPrinted NameDate If the traveler is under 18, parent/guardian signature required: Signature of Parent or GuardianPrinted NameDate  FOR FACULTY & STAFF TRAVELING WITH GROUP ONLY FORMCHECKBOX I am accompanying the group as part of my university duties and have completed a University Travel Leave Form. (DO NOT NEED TO COMPLETE FORM 4) Signature of Faculty/Staff Member Date With few exceptions, you have the right to request, receive, review and correct information about yourself collected using this form. 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