Student Emergency Contact Form Academic Year

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Student Emergency Contact Form
Academic year: 2014-2015
___________________________________________________________________________________________________________
Last Name
First Name
Middle Name
Home Address: ______________________________________________________________________________________________
_____________________________________________________________________________________________
City
State
Zip Code
Date of Birth: _________________________________
Cell Phone: ________________________________________
Home Phone:_______________________________________
Insurance Information (check one): __________ MSM sponsored plan
__________ Other: _______________________________________________________________
Insurance member ID #: ________________________________________________________________________________________
For the 2014-2015 academic year I plan to be:
________ living on campus in Andersen Hall
________ living off campus
IN CASE OF EMERGENCY, CONTACT: (it is helpful to include a local contact if possible)
1)
Name: ______________________________________________
Relationship:________________________________
Cell Phone:___________________________________________
Home Phone: _______________________________
Address: _____________________________________________________________________________________________
_____________________________________________________________________________________________
2)
Name: _____________________________________________
Relationship:________________________________
Cell Phone:__________________________________________
Home Phone: _______________________________
Address: _____________________________________________________________________________________________
_____________________________________________________________________________________________
Are you allergic to anything: _____ No
_____ Yes: ______________________________________________________________
Are you taking any medication we should be aware of: _____ No
_____ Yes: ________________________________________
Do you have any medical/mobility/mental heal concerns we should be aware of: _____ No
_____ Yes (please list below)
___________________________________________________________________________________________________________
The information requested on this card is confidential and for emergency use only. In the event of a medical emergency, this information will be used by
Manhattan School of Music and emergency personnel. Please be honest when completing all pertinent information. In the case o f emergency, I give
permission for my information to be released to emergency personnel. I also agree that any of my emergency contacts listed on this card may be
notified in an emergency, as needed.
_________________________________________________________________________________________
Student Signature
Date

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