EMERGENCY NOTIFICATION AND CONTACT FORM FOR STUDENTS/FACULTY/STAFF

EMERGENCY NOTIFICATION AND CONTACT FORM

Five Towns College utilizes the Blackboard Connect Emergency Notification System to alert its community about important happenings on campus. When circumstances arise, voice and text messages are sent from the Public Safety Office directly to enrolled telephone numbers. Most students/faculty/staff elect to receive emergency notifications on their cell phones and on the landline located at their places of residence. Students/faculty/staff may also enroll additional numbers, with many electing to have emergency notifications sent to the cell phones of their parents, guardians, or spouses as well. Students are enrolled into the Blackboard Connect Emergency Notification System during the admissions process, when they receive a discrete username, password, and instructions on how to make subsequent changes to their enrollment information. Faculty/Staff should complete this Emergency Contact Form as well and submit to the Public Safety Office.

This is important, as students, faculty and staff have a responsibility to remain informed and to keep the Emergency Notification System current, if they change cell phone or landline numbers. Additional information about the Blackboard Connect Emergency Notification System, as well as technical assistance, is available from the Public Safety Office at (631) 656-2196.
EMERGENCY CONTACT FORM
*
- STUDENT
- SUMMER HIGH SCHOOL STUDENT
- STAFF
- FACULTY
Name*
First Last
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Permanent Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home #
Cell #
Email
ID #
PERSONS TO CONTACT IN CASE OF AN EMERGENCY
1. Full Name
Phone
(Telephone number where this person can be most easily reached)
Relationship to You
2. Full Name
Phone
(Telephone number where this person can be most easily reached)
Relationship to You
Health Insurance Provider:
Health Insurance ID #:
SPECIAL HEALTH ISSUES
Please indicate any special health concerns or insurance information that may assist college/healthcare personnel with helping you should an emergency arise: (Examples include: Diabetes, Epilepsy, Heart Condition, Asthma, Special Medication, Allergies, etc.)
Please indicate any special health concerns or insurance information that may assist college/healthcare personnel with helping you should an emergency arise: (Examples include: Diabetes, Epilepsy, Heart Condition, Asthma, Special Medication, Allergies, etc.)
Signature*