Emergency Contact Information

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Last Name:

First Name:

id_num

User Guid:

Use this section to optionally share information with non-clinical College staff who lack access to your confidential medical records - such as your RA, Campus Police, etc. 

Medical Condition:

Allergies:

Medications:

Emergency Contacts - People the College should reach out to in an emergency. List them in priority order.

Emergency Contact 1 - To delete a contact, remove their last name and click submit. 

First Name

Last Name

Mobile Phone:

Relationship (parent/spouse, etc.):

Work Phone:

Home Phone:

Notes:

Emergency Contact 2 - To delete a contact, remove their last name and click submit. 

id_num for Contact 2

First Name

Last Name

Mobile Phone:

Relationship (parent/spouse, etc.):

Work Phone:

Home Phone:

Notes:

Missing Person Contact (if different from above) - Will be contacted if you are reported missing - To delete a contact, remove their last name and click submit. 

id_num for Contact 3

First Name

Last Name

Mobile Phone:

Relationship (parent/spouse, etc.):

Work Phone:

Home Phone:

Notes: