UNLV Emergency Contact Information Form

University of Nevada, Las Vegas
Your name:                                                                                                                              
Your social security number or student number:                                                            
Your email address:                                                                                                                 
Primary Emergency contact’s name:                                                                                         
Primary Emergency contact’s address:                                                                         
City:                                                                             State:                                                   
Zip code:                                                                                                                                 
Emergency contact’s day phone number:                                                                                  
Emergency contact’s evening phone number:                                                                
Fax number and/or cellular phone number:                                                                                
Alternate Emergency Contact’s Name:                                                                         
Alternate Emergency Contact’s Address:                                                                                 
City:                                                                 State:                                                               
Zip Code:                                                                                                                                
Alternate Emergency Contat’s day Phone Number:                                                                  
Alternate Emergency Contact’s evening Phone Number:                                                           
Fax and/or Cell Phone Number:                                                                                               

I hereby give UNLV permission to contact the person above listed in the event of an emergency.

Student Signature                                                                      Date

International Programs - CBC B325
University of Nevada, Las Vegas
4505 Maryland Pkwy Box 456012
Las Vegas  NV  89154-6012
Tel (702)895-3896
fax (702)895-4147