Sport Club: ________________

List below your club’s Emergency Action plan and Travel Roster for ALL Off-Campus Practices and Contests:

EMERGENCY ACTION PLAN

Travel Date(s): __________ Location: ________________

Telephone # of Location: _______________________________

(If telephone number of the location is not known, list a cellular phone number that may be used.)

Number of Cell Phone: ________________________

Name of Person in Charge: ____________________ Social Security #: ________________

Planned response if an Emergency Occurs

(List the names of players/coaches who are First Aid/CPR certified.)

________________________ ________________________

Submitted by (Please print) Date

________________________

Signature

In the event and injury occurs, the following offices should be called:

WCU Public Safety 227-7301

Health Services 227-7640

Emergency 911

Debby Schwartz (W) 227-3553

(H) 277-8143 (C) 712-7450

Please return by the next business day to the Intramural Office, Reid Fitness Center.