RIT Math Competition Emergency Contact Information
Name of Participant _________________________________________________________________________
(including chaperones)
Please list any food allergies___________________________________________________________________
__________________________________________________________________________________________
Emergency Contact Information (Please notify us IMMEDIATELY of any changes to this information). Name
and information of person to contact in case of an emergency:
_________________________________________________________________________________________
NameEmail
_________________________________________________________________________________________
Street
_________________________________________________________________________________________
City
State
Zip Code
_________________________________________________________________________________________
Telephone (work)
(home)
Alternate Contact
Name and information of person to contact in case of an emergency:
_________________________________________________________________________________________
NameEmail
_________________________________________________________________________________________
Street
_________________________________________________________________________________________
City
State
Zip Code
_________________________________________________________________________________________
Telephone (work)
(home)
Health Insurance Information
Name and information of health insurance provider:
Insurance Company _________________________________________________________________________
Policy number _____________________________________________________________________________
Insurance company telephone number __________________________________________________________