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Member Information Form
To be filled out by all members at move in, by new members prior to moving into the house and anytime a member needs to update her information.

Failure to provide accurate information could put you at risk in a medical or other emergency and may result in a fine as determined appropriate by Washington Associates of Nu Chapter.
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Personal Information
First & Last Name *
Please put your legal name with any nickname in parenthesis - for example: Lucille (Lucy) Ball
Cell Phone Number *
Date of Birth *
Where are you living this term? *
If living @1818 please put Main & your room # (if living in annex please put annex & room #), if living out please provide us with the address where you are living.
Email Address *
The email address you check regularly
Member Class *
Expected Graduation Date *
For example: Spring 2029
Current Major *
Parent Contact Information
We consider your parents to be your primary emergency contact.
Parent/Guardian Name *
Parent/Guardian Email *
Parent/Guardian Cell Phone Number *
Parent/Guardian Address *
Secondary Emergency Contact's Name *
Secondary Emergency Contact's Relationship to You *
Secondary Emergency Contact's Home/Cell # *
Secondary Emergency Contact's Email *
Secondary Emergency Contact's Address *
Medical Information
All information provided here will be kept confidential and will be used  in case of emergency and so we know what our members are allergic to so we can plan accordingly (allergies to food, cleaning materials, medications are especially important).
Please list ALL known allergies
*
Please list ALL current medications *
Please list ALL medical conditions and any special health considerations. *
Please list any special dietary needs *
For example - vegetarian, gluten free, dairy free
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