Division of Student Services Emergency Contact Information
Students must complete the below information for the Division of Student Services and Public Safety.
This information is confidential and will only be used by Staff as needed.
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Student Information
Please enter your information
Student Last Name *
Student First Name *
Date of Birth *
MM
/
DD
/
YYYY
Permanent Mailing Address *
Please include City, State and Zip Code
Student Cell Phone Number *
Please include area code
Allergies (if applicable)
Please include any food, medicine, etc. that you are allergic to
Do you carry an epi-pen in the event of an allergic reaction?
Clear selection
Emergency Contact
Please designate an individual to serve as your emergency contact person in the event of an emergency.
First and Last Name *
Relationship to Student *
Address (if different than above)
Cell Phone Number *
Secondary Phone Number
If applicable
Primary Email Address *
Submit
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