Emergency Contact Information Form

* indicates required field

Select a contact:*

PERSONAL INFORMATION

Name:*

Email:*

Phone:*

Cell/Alternate Phone:*

Permanent Address:*

EMERGENCY CONTACTS
One local (in United States) recommended

Full Name (1):*

Relationship (1):*

Home/Cell Phone (1):*

Work/Alternate Phone (1):*

Email (1):

Address (1):*

Full Name (2):

Relationship (2):*

Home/Cell Phone (2):*

Work/Alternate Phone (2):*

Email (2):

Address (2):*

Privacy Notification: The State of California Information Practices Act of 1977 requires the University to provide the following information to individuals who are asked to supply information about themselves: The principal purpose for requesting the information on this form is to provide emergency information. University Policy authorizes maintenance of this information. Furnishing the information requested on this form is voluntary. There is no penalty for not completing the form. The information furnished on this form will be transmitted to the state and federal governments if required by law. Individuals have the right of access to this record as it pertains to themselves.

Privacy Notification

Understood