Alabama A & M University-Normal-UB-Emergency Contact

Alabama A&M University TRiO Bound

EMERGENCY CONTACT INFOMATION
Si desea ver el formulario en español, cambie el idioma en la esquina superior derecha.
Student Contact Information:
Student Name:*

First NameMiddle Int.Last Name
Email*
example@example.com
Student’s Cell Number
(999)999-9999
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1st Contact Parent/Guardian Information:
Parent/Guardian Name:

First NameMiddle Int.Last Name
Relationship to Student
Cell Number
(999)999-9999
Home Number
(999)999-9999
Work Number
(999)999-9999
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2nd Contact Parent/Guardian Information:
Parent/Guardian Name:

First NameMiddle Int.Last Name
Relationship to Student
Cell Number
(999)999-9999
Home Number
(999)999-9999
Work Number
(999)999-9999
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In the event that Upward Bound Staff cannot reach the guardian(s), the following person(s) should be contacted:
Contact's Name:

First NameMiddle Int.Last Name
Relationship to Student
Cell Number
(999)999-9999
Home Number
(999)999-9999
Work Number
(999)999-9999
Contact's Name:

First NameMiddle Int.Last Name
Relationship to Student
Cell Number
(999)999-9999
Home Number
(999)999-9999
Work Number
(999)999-9999
Contact's Name:

First NameMiddle Int.Last Name
Relationship to Student
Cell Number
(999)999-9999
Home Number
(999)999-9999
Work Number
(999)999-9999
Family Physician
Name of Family Physician

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
(999)999-9999
Student’s Health Insurance Information
Name of Insurance Company
Insurance Phone #
(999)999-9999
Policy Number
Name of Insured

First NameLast Name
Insured DOB

MonthDayYear
mm-dd-yyyy
Group Number
NOTICE: Student’s insurance will be filed first, then WCUB insurance will be filed as secondary. All cost NOT covered by insurance, will NOT be the responsibility of the student’s family.
Consent

It is understood that consent is given in advance of any emergency, diagnosis, or treatment required while the student is participating in Upward Bound activities and, that this Medical Release Form authorizes designated school personnel to exercise their best judgement should action be warranted to ensure student’s safety, life, and health.
Please select:

I hereby authorize the medical examination and/or treatments deemed necessary by the attending physician for accidents or illness while participating in Upward Bound. Notify me and/or person(s) listed above as soon as possible.I do NOT permit medical treatment until I have been contacted.
Signature of Parent/Guardian

Clear
Date

MonthDayYear
mm-dd-yyyy

Alabama A&M University TRiO Bound

Student Contact Information:

1st Contact Parent/Guardian Information:

2nd Contact Parent/Guardian Information:

Family Physician

Student’s Health Insurance Information