BUSINESS AND FINANCIAL SERVICES
EMERGENCY CONTACT INFORMATION
Your Name:
Home Phone:
Cell Phone:
Division:
Alt Phone:
Status (circle one):
Faculty
Staff
Student
Temp
Volunteer
Emergency contacts (please list in the order you wish them to be called)
Name:
Relationship to you:
Phone #1:
circle one: home
work
mobile
Phone #2:
home
work
mobile
Name:
Phone #3:
home
work
mobile
work
mobile
work
mobile
Relationship to you:
Phone #1:
circle one: home
work
mobile
Phone #2:
home
work
mobile
Name:
Phone #3:
home
Relationship to you:
Phone #1:
circle one: home
work
mobile
Phone #2:
home
work
mobile
Phone #3:
home
HEALTH INSURANCE INFORMATION
Yes I have health insurance.
No I do not have health insurance.
If yes:
Name of insurance provider:
Name of Primary Care Physician:
Emergency phone number for provider:
I give the UCSD Business and Financial Services the right to contact the above named person(s)
for the sole purpose of responding to an emergency.
Signature
Date