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# KENTUCKY STATE UNIVERSITY SCHOOL OF NURSING EMERGENCY CONTACT FORM

Please print

Student ID: ___



Full name (First, Middle, Last)

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.

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<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td style='text-align: center; word-wrap: break-word;'>Full Name of Contact</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'>Relationship to Student</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Home Phone</td><td style='text-align: center; word-wrap: break-word;'>Work Phone</td><td style='text-align: center; word-wrap: break-word;'>Cell Phone</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Street Address</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'>City</td><td style='text-align: center; word-wrap: break-word;'>State</td><td style='text-align: center; word-wrap: break-word;'>Zip</td></tr><tr><td style='text-align: center; word-wrap: break-word;'>Student Signature</td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'>Date</td></tr></table>