Member Emergency Form
First Name ____________________________
Sport Club ____________________________
Last Name _________________________ ____
Student ID # ____________________________
Local Address: ____________________________________________________________________
City ______________ State ________ ZIP ________
Phone# _____________________________
Email address_______________________________@winthrop.edu
Age __________________
Emergency Contact Information
Emergency Contact _______________________________
Relationship _________________
Address ______________________________City _______________State ____ _ Zip____________
Phone # ______________________________
Alt. Phone # _______________________________
All members must have medical insurance to participate in a club sport. Copies of health insurance
must accompany this form. This information will only be used in the event of an emergency.
Health Insurance Information
Company Name_________________________________ Policy Number________________________
Group Number__________________________________ Expiration___________________________
Verification of Information
I certify that to the best of my knowledge, the information on this card is correct. I understand that I must
notify the Office of Recreational Services immediately of any changes to the information listed above.
____________________________________________
Member’s Signature
Print Form
________________________________
Date