EMERGENCY / MEDICAL / CONTACT INFORMATION
Name _____________________________________________ WKU ID# ___________________________________
Residence Hall _______________________________ Room # __________ Cell Phone # _____________________
Person to contact in case of emergency:
Name ______________________________ Relationship ___________________ Phone # ____________________
Person(s) to contact in case you are determined to be missing by the university:
Name ____________________________________________________ Phone # ____________________________
Have you received the meningitis vaccination? ______ No ______ Yes
Do you wear contact Lenses? ______ No If yes, ______Hard ______ Soft
List medical conditions we should be aware of (allergies, diabetes, epilepsy, heart condition, etc.):
_____________________________________________________________________________________________
List prescription drugs that you are taking that we should be aware of: ___________________________________
_____________________________________________________________________________________________
Insurance Company ____________________________________________ Policy __________________________