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CAL POLY STUDENT TRAVEL EMERGENCY INFORMATION CARD

Club Name: Dates of Travel Destination:

Form CT-3

Student Information
Student's Name: Local Address Phone Number E-mail Student ID #

Emergency Contact Information

Name: Phone Number Relationship: E-mail

Insurance and Vehicle Information

Medical Insurance Company Policy Number Auto Insurance Company Policy Number Vehicle Make Vehicle Year Vehicle License Plate Name of Policy Holder Phone Number Driver's License # Expiration Date Vehicle Model Vehicle Color