CLIA In Case of Emergency & Personal Data

 Please print all info  

Name (Given & name you like to be called) 

Home Address City  State Zip 
Home Phone/Cell 
Email home /school  
Area(s) of Certification 
School Name 
Address City State Zip 
School Phone 
School District  
Grade level /classes 
Years of Teaching  

Housing requests:  Please note roommate preference:______________________________________________

Housing not needed :______( there may be evening events pending schedule)Medical Considerations: 

Please share here or with Kathe Stanley any physical limitations or conditions that might impact you during your stay at CLIA. 

If you will need a single room (sharing bath) please note. _____________________________________________________________________________________________________

Contact Information:  In case of an emergency CLIA staff may contact:

Emergency Contact Person: ___________________________________________________________________

Relation to you:_____________________________________________________________________________

Phone numbers, including area code and extension/cell number: _____________________________________

Permission:  In the event of an emergency (illness or accident) at CLIA and the above emergency contact person cannot be reached, I give CLIA staff permission to seek emergency medical care on my behalf.

Signature_________________________________________________________Date: ____________________