Emergency Contact Information

Please complete the form below to provide us with your emergency contact information.

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Student Name

First Last

Cell Phone(Required)

Home Phone

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Primary Emergency Contact Name

First Last

Primary Emergency Contact relationship to the student

Primary Emergency Contact Cell Phone(Required)

Secondary Emergency Contact Home Phone

Secondary Emergency Contact Name

First Last

Secondary Emergency Contact relationship to the student

Secondary Emergency Contact Cell Phone(Required)

Primary Emergency Contact Home Phone

Preferred Local Hospital(Required)

(Closest to campus is University Medical Center or Lafayette General Hospital)

Insurance Company(Required)

Policy #(Required)

Signature(Required)

Date(Required)

AIE enrollment