Student Emergency Contact Form
This form is used to assist in case of an emergency. All information will be held in strict
confidence and will be destroyed at the conclusion of your placement.
University:
_____________________________________________________________________
Student Name:
_____________________________________________________________________
Home Address:
_____________________________________________________________________
Phone number:
_____________________________________________________________________
Date of Birth:
_____________________________________________________________________
Email Address:
_____________________________________________________________________
Emergency Contact 1 (Name):
______________________________________________________
Relationship:
______________________________________________________________
Phone Number:
______________________________________________________________
Does this contact know you are on placement? __________________________________________
Emergency Contact 2 (Name):
_______________________________________________________
Relationship:
______________________________________________________________
Phone Number:
______________________________________________________________
Does this contact know you are on placement?
________________________________________
Please indicate any medical conditions or disabilities which may impact on your
ability to undertake your placement? (eg; physical conditions, allergies etc)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Are all your immunisations current?
Yes
No
Please refer to link for further information on Immunisations:
acement/
1