Emergency Contact Information Form - University Of Northern Iowa
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1Personal Data and Emergency Information Sheet
University of Northern Iowa ‐ Department of Residence
Students: Please have this Personal Data and Information Sheet complete and provide it to the residence hall staff when you arrive on
campus. This information may be used to identify medical information, medications, special needs, or to contact you in case of
emergency. It will only be available to necessary officials, including staff in the Department of Residence, University Police, University
Health Services, and emergency medical personnel.
Personal Information Sheet
Hall: _____________________________
Room #: ______________________
Student ID#: _____________________
Cell phone #: _______________________________ Date of Birth: _______________________________
Student Information:
Name: ________________________________________________________________________________
Last
First
MI
Permanent Address______________________________________________________________________
Street
City
State
ZIP
Class Rank: ___Freshman ___Sophomore ___Junior ___Senior ___Graduate
Medical Insurance Provider_______________________________
Any physical / emotional health condition(s) the residence hall staff should be aware of:_______________
____________________________________________________________________________________________________________
Allergies to Medications/Environment/Foods
Medical Name Describe Reaction
__________________________ _____________________________________________________
__________________________ _____________________________________________________
Medication List: Prescription and over the counter drugs and purpose for taking.
Include dose and frequency.
1.______________________________________________ 2.________________________________________________
Parent or Guardian Information:
In case of emergency, I give permission for the following person(s) to be contacted:
______________________________________________ ________(______)_______________________
Name
Cell phone number
_____________________________________________________________________________________
Relationship to Student
Email address
____________________________________________________________________________________
Street
City
State
Zip
Information Regarding Missing Persons:
If you are reported missing, the University is required to notify your emergency contact within 24 hours if you are determined to be
missing by law enforcement. If you are under the age of 18, such emergency contact must be made to a parent or legal guardian. If
you believe another student is missing, you should contact UNI Police immediately at (319) 273‐2712. If you'd like someone other than
the above mentioned emergency contact notified in the event you are reported missing, please provide that information below.
The information contained in this document will be kept confidential and is being compiled to comply with the Higher Education
Opportunity Act (HEOA) and related amendments. Details regarding the University Missing Persons Policy are contained in the annual
security report published by University Police and available online at:
hard copy of the report is available for public inspection in the Dean of Students Office, 118 Gilchrist Hall. (319) 273‐2332.
______________________________________________________(_____)__________________________
Name
Cell phone number
_____________________________________________________________________________________
Relationship to Student
Email address
____________________________________________________________________________________
Street
City
State
Zip
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