Domestic Internship Emergency Information 2008

This form provides you and our office valuable information in case of emergency. Please fill out the form completely and print at least two copies for your record. We recommend you give a copy of this information to both your internship supervisor and program coordinator (if applicable).

Please note: Required fields are followed by an asterisk (*).

	Intern Information
First Name:	*
Middle Initial:
Last Name:	*
	Contact Information
Permanent address:	*
Telephone:	*
	Summer Contact Information:
Address:	*
Phone Number:	*
	Parent/Guardian Information:
	Parent/Guardian #1 Information:
Name:	*
Address including street, city, state, zip code and country:	*
Home phone number:	*
Work phone number:	*
Fax Number:	*
Email Address:	*

	Parent/Guardian #2 Information:
Name:
Address including street, city, state, zip code and country:
Home phone number:
Work phone number:
Fax Number:
Email Address:

	In addition, if I have a medical or security emergency, please call the following, in order:
First to call name:	*
First to call relationship:	*
Address including street, city, state, zip code and country:	*
Home phone number:	*
Work phone number:	*
Fax Number:	*
Email Address:	*
Second to call name:
Second to call relationship:
Address including street, city, state, zip code and country:
Home phone number:
Work phone number:
Fax Number:
Email Address:

	Summer Supervisor Contact Information:

	Supervisor #1 Information:
Name:	*
Organization:	*
Address including street, city, state, zip code and country:	*
Work number:	*
Fax number:	*
Email:	*
	Supervisor #2 Information:
Name:
Organization:
Address including street, city, state, zip code and country:
Work number:
Fax number:
Email:
	List contact information for the following places:
The closest hospital:	*
The closest women's center/rape crisis center:	*
I have the following allergies/medical concerns:

List the following information on your printed copy of this form.

Note: A short amount of time today will save a big headache later.
Insurance Information (health, liability, evacuation, etc.)
Travelers Check Numbers and the number to call if they are lost or stolen
Credit Card/Bank Card phone numbers to call if they are lost or stolen
Do notwrite your credit card or PIN numbers on this sheet

For more information contact Beth Robichaud, CWS, erobicha@wellesley.edu, ext. 2254.