Resident's Emergency Information

Please provide Huron University College with the following information for use in an emergency. Please note that you are able to access this information sheet at any time in order to verify its accuracy. The information is used to ensure key medical and contact information is available for emergency purposes and will be provided to emergency and/or University personnel as required. If you have questions about this collection, use or disclosure of this personal information, please contact the Director of Housing and Organizational Services for Huron University College at (519) 438-7224 ext. 204 or huronrez@huron.uwo.ca.

* = required fields

(provision of health number is voluntary)

Permanent Address

Emergency Contact

Medical Information

Please note any important information (physical or mental health issues) below. Check those that apply.

Medications (For each of the following, check either "yes" or "no" and if yes be specific)

Prescribed Medications
Drug Allergies

Medical Conditions (For each of the following, check either "yes" or "no" and if yes be specific)

Serious Allergies
Asthma
Mental Health Issues
Diabetes
Epilepsy
Others

Family Physician

Consent

By checking this box, I hereby give Huron University College my consent to use the information on this form in the event of an emergency, to contact the emergency contact person indicated, and to disclose the information to emergency services personnel.