Emergency Medical Data

In case of emergency, the information supplied below will be provided to the emergency services personnel (hospital, ambulance, etc.).

Required fields are indicated by an asterisk (*)
General Info - Please answer the following questions
First Name*: Last Name*: Dorm & Room #:
Home Address*:
City/Town*: State/Province*: Zip/Postal Code*:
Home Phone Number*:
(e.g. xxx-xxx-xxxx) 		Email*:
Religion: (please provide if your religion prohibits certain forms of medical treatment)
Person to Notify in Case of Emergency*:
Relationship
to you*:
(e.g. Father) 		Phone Number*:
(e.g. xxx-xxx-xxxx)
Medical Information
Are you currently under medication? Yes No
If yes, please list them:
Are you currently using medical needles?
(If yes, Physical Plant will provide appropriate disposal boxes.) 		Yes No
Allergies:
Do you have a history of:

Heart Disease?
Diabetes?
High Blood Pressure? 		 

Low Blood Pressure?
Epilepsy?
Hearing Loss? 		 
List any other medical condition:
Blood Type:
 RH Factor:
 Year of last Tetanus shot:
  
Are you an organ donor? Yes No     If yes, please specify:
Insurance Information
Insurance Company: Group Number:
Name insurance is under:

Please verify that all required fields have been filled and that all information is to your knowledge accurate. Once you have looked over the form for accuracy, please submit this form.