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KENTUCKY STATE UNIVERSITY
SCHOOL OF NURSING
EMERGENCY CONTACT FORM
Please print
Student ID: ___
Full name (First, Middle, Last
Full name (First, Middle, Last)
Student ID: ___
Student ID
Emergencies sometimes occur when you are in the clinical field. Please identify an individual that you authorize the School to contact in these situations and provide the requested information below.
Emergency situations may include instances where you must be removed from the academic setting (clinical or classroom) due to medical conditions and require transportation to a medical treatment facility.
Best practices dictate that you keep this information updated with the School and your clinical instructors.
*****
Full Name of Contact
Relationship to Student
| Full Name of Contact | Relationship to Student | |
|---|---|---|
| Home Phone | Work Phone | Cell Phone |
| Street Address | ||
| City | State | Zip |
| Student Signature | Date |
Home Phone
Work Phone
Cell Phone
Street Address
City
State
Student Signature
Zip
Date