I understand that there is always some small amount of risk when going on an extended field trip, and that all normal/reasonable precautions will be taken for my safety.  In the event that I require medical care, I will not hold responsible Dr. Tomasi, the Department of Biology, Missouri StateU, the state of Missouri, or any governing bodies thereof.

Should I require medical care while on this trip and am unable to make my own medical decisions, Dr. Tomasi is authorized to make these on my behalf.  Any special medical concerns that I have (allergies, diseases, attacks of various natures, drug reactions, etc) that I have are listed here:






______________________________________                _______________
Signature                                                                               Date


Medical Insurance provider:  ___________________________________

  Name on insurance coverage: ___________________________________

  Group # _________________       Account # _____________________

  Emergency phone number for insurance: __________________________

People I would like notified in case of medical emergency (PRINT up to three):

 Names                                                Relations                         Phone numbers

______________________                ___________                _____________________

______________________                ___________                _____________________

______________________                ___________                _____________________