Student Emergency Contact Record

Student Emergency Contact Record

2022-2023
Student Information
Date of Birth*

MonthDay Year
Date
Student Number*
Name*

First Name Middle Name Last Name
Primary Phone Number*

Area Code Phone Number
Alternative Phone Number

Area Code Phone Number
Primary Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact Information
Primary Contact*
Phone Number*

Area Code Phone Number
Secondary Contact
Phone Number

Area Code Phone Number
Medical Information
Doctor*
Phone Number*

Area Code Phone Number
City and State*
Allergies*
If none, add none.
Medications*
If none, add none.
Medical Conditions*
If none, add none.
The information provided on this form is accurate to the best of my knowledge and I have indicated any special health conditions that should be known to Campus Life Staff and medical personnel. If I am unable to give consent in the event of an emergency, I hereby give permission to medical personnel to administer emergency medical treatment.
Signature*

Clear
Name*

First Name Last Name
Date*

MonthDay Year
Date
Should be Empty: