Update Emergency Contact Information
Purpose: Used to provide, correct, or update emergency contact information on record with the University.
Section 1: Student Information
Signature Date
Are you currently enrolled?
If No: Year of Last Attendance
Yes No
Student Instructions:
1. Complete Sections 1-3 of this form, using a computer.
2. Print the form using the 'Print Form' button.
a. a handwritten form will not be accepted.
b. an incomplete form will not be processed and will be returned to you for completion.
3. Sign the form in Section 4; a digital signature is not acceptable.
4. Submit request via one of the methods listed at the bottom of this form.
Rev 12/2015
Section 3: New Emergency Contact Information
Last
MiddleFirst
Contact Name
NoYes
Primary Contact?
Address
Phone Type:
WorkCellHome
ZipState
City
Street
Section 4: Student Statement/Signature
I certify that all the information above is correct and request that my emergency contact information be updated as indicated above.
Phone
Former Name(s) MUID
Email
(current students use your Marquette email address)
Date of Birth
MM/DD/YYYY
Relationship to student
Phone
NoYes
Section 2: Remove Emergency Contact Information
Remove primary emergency contact?
If Yes, enter the name of the primary emergency contact to be removed
If Yes, enter the name of the other emergency contact to be removed
Remove other emergency contact?
NoYes Not applicable
Hand Deliver: Marquette Central, Zilber Hall, 121, 1250 West Wisconsin Avenue, Milwaukee, WI 53233
Mail: Marquette University, Zilber Hall, 221, P.O. Box 1881, Milwaukee, WI 53201-1881
Email: otrdocs@marquette.edu
Name
Last name, First name, Middle name
Mailing Address
street address, city, state, zip code
