Medical Insurance Information Form

2016 Summer Academic Institute

Student's Name:*

Home Address:*

Home Telephone Number:*

Student's Cell Phone Number:

Email Address:*

Date of Birth:*

Age:*

EMERGENCY INFORMATION (Please provide two names at two different addresses)

Name of 1st emergency contact:*

Relationship to you:*

Daytime Telephone Number:*

Evening Telephone Number:*

Name of 2nd emergency contact:*

Relationship to you:*

Daytime Telephone Number:*

Evening Telephone Number:*

Are you currently covered under a medical insurance plan?

Yes

Name of Medical Insurance Plan:

Name of Policy Holder:

I.D. Number:

Group Number:

Effective Date:

Expiration Date:

Opportunity Program Contact

518-580-5770

518-580-5781

Opportunity Program
Skidmore College
815 North Broadway
Saratoga Springs, NY 12866

Ladd Hall 100

Monday - Friday
8:30 a.m. to 4:30 p.m.