Admissions: Emergency Medical Data - University of Maine at Fort Kent

Accepted

Emergency

Tuition Break for New England Students

Emergency Medical Data

In case of emergency, the information supplied below will be provided to the emergency services personnel (hospital, ambulance, etc.).

Required fields are indicated by an asterisk (*)

Please Answer the Following Questions
First Name*	Last Name*	Dorm & Room
Home Address*
City/Town*	State/Province*	Zip/Postal Code*
Home Phone* (e.g. xxx-xxx-xxxx)	Email*	Religion1
1 (please provide if your religion prohibits certain forms of medical treatment)

Person to Notify in Case of Emergency
Name*	Relationship to you* (e.g. Father)	Phone Number* (e.g. xxx-xxx-xxxx)

Medical Information

Are you currently under medication? Yes No

Do you have a history of:

If yes, please list them:

Are you currently using medical needles? Yes No (If yes, Physical Plant will provide appropriate disposal boxes.)

Allergies:

List any other medical condition:

Blood Type: RH Factor:

Year of last Tetanus shot:

Are you an organ donor? Yes No

If yes, please specify:

Insurance Information
Insurance Company:
Group Number:
Name insurance is under:
Please verify that all required fields have been filled and that all information is to your knowledge accurate. Once you have looked over the form for accuracy, please submit this form.

23 University Dr., Fort Kent, ME 04743 • PO Box 1041, Clair, NB E7A 2J5

University of Maine System • 16 Central Street, Bangor, ME 04401

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