Salt Lake Community College
International Travel Emergency Contact &
Health and Welfare Form
Traveler Information:
SLCC S#:
Traveler Name:
Cell phone:
Email:
Passport number:
Health Insurance Information
Health Insurance carrier:
Health Insurance Phone number:
Health Insurance policy number:
Please attach a copy of your insurance card.
Emergency Contact (required):
You authorize SLCC, its employees or agents to notify the person listed below in case of an
emergency.
Emergency Contact Name:
Relationship:
Work Phone:
Cell Phone:
Email:
Signature:
