Lake Erie College - Residence Life - Emergency Information Form

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Emergency Information Form

All residential students must have health insurance. The information provided may be used as needed by other college personnel when an emergency arises. This form must be filled out completely and returned to the Student Life Office prior to a student’s arrival on campus. A student will not receive his/her key without this form on file. Please mail this form in the enclosed envelope to:

The Housing Office, Box 344, 391 W. Washington St., Painesville, OH 44077.

Student's Full Name:
Address:
City
State
Zipcode
Cell Phone:
Date of Birth:
Insurance Company:
Policy/Group #

Please list 3 Emergency Contacts Below (we will call in the following order):

1.	Name:		Relationship:
	Day Phone:		Evening Phone:

2.	Name:		Relationship:
	Day Phone:		Evening Phone:

3.	Name:		Relationship:
	Day Phone:		Evening Phone:

Please list any allergies:

PERMISSION FOR TREATMENT

I hereby give voluntary consent to the appropriate College official to sign any papers necessary for hospital treatment, admission, anesthesia and/or surgery. In addition, I give consent for appropriate treatment should a need for psychological care be indicated by my child or by the College.

In case of emergency involving my child/self, I also give my consent to the physician to treat my child/self for both routine and emergency medical and surgical conditions.

Parent/Guardian:		Date:
By checking this box I verify I am the Parent or Guardian.

Student:		Date:
By checking this box I verify I am the Student.

IMPORTANT: When admitted to the hospital for care or surgery, the doctor in charge and the Director of Community Living will make every possible effort to notify the parent(s)/guardian(s) of the situation.

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Lake Erie College • 391 West Washington Street • Painesville, Ohio 44077
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