SLI-TE Programs and Registered Student Organizations: Excursion Emergency Contact Form and Liability Waiver

The below is a digital version of the Excursion Emergency Contact Form required by The New School for any off-campus excursion or event.

This Google form is specifically for Registered Student Organizations under support of the Office of Student Leadership and Involvement (SLI). If you list an external department, group, or division of SLI, this form will not be connected to them or their requirements.

This digital version is operated and maintained by Gilles Stromberg in the Office of Student Leadership and Involvement. For any questions or concerns, please email them at strombeg@newschool.edu

Write your first and last name and your New School email address.

Write the name of the off-campus event or excursion.

Write the name of the Office, Department, or Registered Student Organization (RSO) hosting this event:

Date(s) of the event:

Student's full legal name:

Student's TNS ID (N Number):

Student's local address, including Street address/apartment number, City, State, Zip code:

Student's phone number:

Student department division (Check the Division[s] of your Major):

Parsons

Lang

Jazz

Mannes

NSSR

NPSE

Drama

Health Insurance Information: Provider Name/Name of Company

Health Insurance Information: Policy Number

In the event of an emergency, will you be able to hear fire alarms or other signals, see written instructions or signs, or walk down the stairs to the nearest exit without assistance? (YES or NO)

If additional clarity is needed, please provide information in the box below.

Please describe any medical condition or disability you have and indicate any medications you are taking:

Person 1 - In the event of an emergency, please contact the below person:

Share their full name (If you are under 18 years of age, please indicate the name of a parent/guardian). All emergency contacts must reside in the United States.

Student's relationship to Person 1:

Examples include: Roommate, Partner, Parent, Sibling, Aunt, Uncle

Person 1's Full Domestic Address:

Include Street Address, Apartment/Unit #, City, & Zip Code

Person 1 - Home Phone Number:

Person 1 - Work Phone Number:

If the number is the same as the Home phone number (ex: Mobile), that's okay

Person 2 - In the event of an emergency, please contact the additional below person:
Please share their full name (If you are under 18 years of age, please indicate the name of a parent/guardian). All emergency contacts must reside in the United States.

Student's relationship to Person 2:

Examples include: Roommate, Partner, Parent, Sibling, Aunt, Uncle

Person 2 - Home Phone Number

Person 2 - Work Phone Number:

If the number is the same as the Home phone number (ex: Mobile), that's okay