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AWE Pre-Orientation Confirmation

We're excited to have you attend AWE Pre-Orientation 2012! Please fill out the following information AND the packet of paperwork linked below. If you have any problems or questions, contact us at awe@seas.upenn.edu or 215-573-6487. Please submit ALL information (on-line and mailed paperwork) by Friday, July 27, 2012.

Contact Information
First Name
Last Name
Penn card number
Penn email address
Campus Housing (Building & Room)
Cell Phone Number

Medical Information
Participant is allergic to the following medications:

Please specify any food allergies you suffer from:

Other medical conditions that you wish for those providing treatment to be aware of:

Insurance Information
Is Participant covered by the University of Pennsylvania health insurance plan?
If no, what insurance plan are they covered by?
Name of insurance company
Policy or plan number(s) (*Please provide ALL numbers and/or codes to identify your plan or policy and mail a photocopy of your membership card or policy document with your forms.)

Name of subscriber to policy or plan
Relationship to participant
Name of participant

Program Contact Information
Participant's birthdate
Two emergency contacts and 24/7 contact information is required:
1. Name
1. Relationship to participant
1. Day phone number
1. Evening phone number
1. Cell phone number
1. Street Address
1. City
1. State
1. Zip Code
1. Email address
 
2. Name
2. Relationship to participant
2. Day phone number
2. Evening phone number
2. Cell phone number
2. Street Address
2. City
2. State
2. Zip Code
2. Email address

In addition to the information above, you also need to sign and return this paperwork along with your Pre-Orientation fee. Paperwork packet includes:

  • Welcome Letter
  • Waiver and Release
  • Participant Agreement
  • Credit Card form (if needed)

Questions? Contact Michele Grab at 215-573-6487 or mgrab@seas.upenn.edu