Laker Athletics Activity/Program Release and Waiver of Liability

Mid Michigan College Student Emergency Contact Form Waiver & Release
Student Name*

First NameMiddle NameLast Name
Mid Michigan College Student ID Number*
You can find your Mid Michigan College Student ID Number on your Mid Michigan College Student ID Card or in myMid.
Phone Number*

Area CodePhone Number
Mid Mich Email*
example@midmich.edu
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth*

MonthDayYear
Note any medical conditions or allergies. If none, enter N/A.*
Travel Information
Is the travel connected to a Laker Athletics team?*

YesNo
For which team are you travelling?*

BaseballMen's BasketballWomen's BasketballBass Fishing (co-ed)Men's BowlingWomen's BowlingClay Target Shooting (co-ed)Men's Cross CountryWomen's Cross CountrySoftball
Trip Name*
Trip Destination*
Trip Start Date*

MonthDayYear
Trip End Date*

MonthDayYear
Name of Activity/Program Director*

First NameLast Name
Mid Mich Email of Activity/Program Director*
example@midmich.edu
Health Insurance Information
Health Insurance Carrier*
Group #*
Policy #*
Carrier Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Carrier Phone Number*

Area CodePhone Number
Insured Name*

First NameLast Name
Relationship to the Insured*
Emergency Contact Information
Name of your Emergency Contact*

First NameLast Name
Relationship to Emergency Contact*
Address of Emergency Contact*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number for Emergency Contact*

Area CodePhone Number
Email for Emergency Contact*
example@example.com
Facebook Profile of Emergency Contact
Please include name of profile and primary town/state.
I hereby authorize Mid Michigan College to notify the above individual in case of emergency and release information regarding my health, safety, or legal status in order to secure any necessary assistance to my well-being.*

I verify my understanding with the e-signature captured below.I do not understand and need clarification.
Student Signature*

Clear
Date*

MonthDayYear
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In its commitment to providing a safe environment, Mid Michigan College actively endeavors to broaden our diversity, promote equal opportunity, and prohibit any form of discrimination in its programs, activities, and conditions of admission or employment. Learn more about these efforts and policies by visiting midmich.edu/eeo, midmich.edu/titleix, midmich.edu/securityreport.
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Mid Michigan College Student Emergency Contact Form Waiver & Release

Travel Information

Health Insurance Information

Emergency Contact Information