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Emergency Contact Form

First Name:
Last Name:
Student ID#:
Cell Phone:
	E2Campus Enrollment
	By checking this box your cell phone number will be enrolled in the Greensboro College E2Campus Emergency Notification System. You may also enroll additional family members' phone numbers by visiting the Greensboro College IT web site.
Residence Hall:
	If Applicable
Room #:
	If Applicable
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Email:
Emergency Contact Home Phone:
Emergency Contact Cell Phone:
Do you have any allergies we should be aware of?:
Please list any medications you are taking::
Is there any additional information we should have to act on your behalf in an emergency?:
Please list any additional individuals you would like us to contact if the one listed above can not be reached.:
	Electronic Signature
	By checking this box you are authorizing Greensboro College officials to contact the above listed individual(s) on your behalf in the case of an emergency. Emergency situations include but are not limited to: injury, illness, hospitalization, or missing person notification.