Contact Information for Class Field Trips

In the event of an emergency while on a geology class field trip, please provide the following information:

Academic Year:    2017-2018
 
Course Number:
Instructor:
Dates of Field Trip:
 
Your Name:
I am a:
If "Other", please describe below.
Campus Address:
Phone:
Email:
 
Emergency Contact Name:
Contact Address:
Contact Phone:
Contact Email:
 
Please provide the name of your medical insurance carrier and a policy number below.
Insurance Carrier:
Policy Number:

**If you have a special health condition that an attending physician must know of in the case of an emergency, please provide the information in a sealed envelope to the supervising faculty member of your field trip.  The faculty member will keep the sealed envelope until the trip is over and then return it back to you.**

In case of an emergency contact Caltech Security at 626-395-4701 , or extension 5000 from campus phones.

GPS Contact People

Aleen Boladian: 626-395-6206
John Grotzinger: 626-395-6108
Rob Clayton: 626-395-6909
Jen Shechet: 626-395-6111

Please print a copy for your records , then click the "Submit" button below to submit this form electronically.
Alternately, you can use campus mail to send the form to:

Julie Lee
MC 170-25