Emergency Information Form

This Emergency Information form is important for the Office of Residence Life to have on file. This form requests any medical conditions, as well as emergency contact information, family physician and insurance provider. It is imperative that you fill out this form completely, and that you notify Health Services of any changes throughout the year. This will complete the paperwork portion of your housing application.

If you have any further questions about this process, please call the Office of Residence Life at (618) 537-6548 or e-mail the Assistant Director of Residence Life at jteddington@mckendree.edu.

We look forward to seeing you!

Name

Date of Birth Gender Male Female

In Case of Emergency, Notify:

Name Phone

Address

Relationship

City, State, ZIP

Medical Information: (check all that apply)

Epilepsy Medication

Diabetes Medication

Asthma Medication

Other Medication

Allergies (please list):

Medications currently being taken:

Insurance Provider

Insurance ID number

Family Physician

Name

Phone

Address

City, State, ZIP

Emergency Information Form

McKendree University