Pacifica Graduate Institute STUDENT EMERGENCY INFORMATION

This form will be kept in the Transportation/Security Office of Pacifica Graduate Institute and made available to non-Pacifica personnel if Pacifica determines, in its sole discretion that there is an emergency and the student so consents.

Last Name *

First Name *

Middle Name

Program *

Track *

Person to contact in case of emergency:

First Name *

Last Name *

Relationship: *

Address *

City *

State

Country

Daytime Phone Number *

Evening Phone Number *

Email Address

The following information is requested for your protection and convenience but is not mandatory:

Special health related needs or conditions:

Allergies:

Blood Type:

Current Medications:

Please check one: *

I hereby consent to this form being made available to other than Pacifica personnel if Pacifica determines, in its sole discretion, that there is an emergency.

I refuse consent to this form being made available to anyone other than Pacifica personnel under any circumstances, including an emergency, and hereby release and waive any and all claims against Pacifica, for bodily injury, medical expenses or otherwise resulting from Pacifica not making this form available.

I understand that in the event of an emergency it is the procedure of Pacifica, in its discretion, to call 911 to request emergency services. I hereby agree to indemnify Pacifica for any and all costs incurred in connection therewith. I further understand and agree that Pacifica shall have no responsibility for emergency medical or other treatment. I hereby release Pacifica from all liability in connection with its actions or non-action to obtain such treatment and for the actions or non-action of any person or persons providing such emergency assistance or treatment. I hereby acknowledge and understand that Pacifica does not maintain: any medically or emergency trained personnel on campus; or medical insurance for its students, and that obtaining and payment for medical care while a student at Pacifica is my responsibility. In the event that I wish emergency medical treatment or transportation through some means other than that provided by 911, I will bear sole responsibility for making such arrangements and payment for such services and transportation.
Please sign and date: *

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