Personal 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: http://www.vpaf.uni.edu/pubsaf/crime_stats/clery.shtml. A 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