Your website

Information for Participant, Emergency Contact, and Accommodation

The information on this form is collected by SFU under the authority of the University Act (RSBC 1996, c.468) and the Freedom of Information and Protection of Privacy Act (RSBC 1996, c.165). It is related directly to and needed by the University to help ensure the health and safety of individuals participating in non-classroom activities such as in working, learning or research field activities within the Faculty of Environment. The information will be used to ensure your health and safety during the non-classroom activities. If you have any questions about the collection, use and disclosure of this information please contact Peter Locher, Field Operations Manager, TASC 2 8906, email: plocher@sfu.ca. * Indicates a required field.

Course Number (e.g., GEOG 111)

Participant Information

First Name

Last Name

Nee (optional)

Student Number

Telephone Number

Email Address

Address of Participant format: Street address, City, Provice/State, Country

I am not the full age of nineteen (19) years or older.

Participant Pre-existing Conditions

The information collected in this section will be kept strictly confidential. The information collected below is to inform the Team Leader of any participant pre-existing conditions that may compromise the health and safety of any/all individuals participating in the non-classroom activity associated with the course identified above - the information collected below will help ensure the health and safety of the individuals participating in the non-classroom activity associated with the course identified above.

I, the Participant, have a pre-existing condition (physical, medical, psychosocial, or other) that may compromise my health and safety, or the health and safety of others; examples of pre-existing conditions may include, but are not limited to: food allergies and/or cardiopulmonary conditions that require medication. The pre-existing conditions that I, the Participant, have are written in the text box below (if none, please write "not applicable"):

Emergency Contact Information

Emergency Contact Person (Last name, First name):

Relationship to Participant

Emergency Contact Person Telephone Number

Emergency Contact Person E-mail Address

Accommodations

The field trip related to the course outlined above requires overnight travel Yes No

If the field trip related to the course outlined above requires overnight travel, I (the Participant) intend to stay in accommodations arranged by Simon Fraser University Yes No Not applicable

If I, the Participant, am required to participate in a field trip that requires overnight travel but elect not to stay in accommodations arranged by the Department of Geography (Simon Fraser University), I hereby provide my accommodation arrangements:

Name of Lodging

Address of Lodging

Telephone Number of Lodging

Room Number

Submission

Date of Sign

Spam protection: please select the check box below

Faculty of Environment