Three Emergency Contacts for Telehealth Counseling , Psychological, and Mental Health Medication Evaluation Services

Student Health and Counseling Center

P.O. Box 755580, 1007 N. Chandalar Drive | Fairbanks, AK 99775-5580 | PH: 907-474-7043, FX: 907-474-5777| www.uaf.edu/chc
Three Emergency Contacts for Telehealth Counseling, Psychological and Mental Health Medication Evaluation Services.

Please provide us with the names and contact information of three trusted people your provider can contact if there is a technology failure and/or a health and safety concern.
Your Name*

First NameLast Name
Your UA Student Identification Number
Your Date of Birth*

MonthDayYear
Date
Contact #1's Name*

First NameLast Name
How is this person related to you?*
Contact #1's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact #1's Telephone Number*
xxx-xxx-xxxx
Contact #1's Email Address
example@example.com
Contact #2's Name*

First NameLast Name
How is this person related to you?*
Contact #2's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact #2's Telephone Number*
xxx-xxx-xxxx
Contact #2's Email Address
example@example.com
Contact #3's Name*

First NameLast Name
How is this person related to you?*
Contact #3's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact #3's Telephone Number*
xxx-xxx-xxxx
Contact #3's Email Address
example@example.com
By signing this form,

I hereby authorize the UAF STUDENT HEALTH AND COUNSELING CENTER to contact the three people listed on this form in the event my counselor has concerns about my health and well-being and/or is unable to contact me due to technology failure.

I understand that I may revoke this authorization at any time in writing. The revocation will not change any action taken between the date of the original authorization and the date of the revocation is received by UAF SHCC.
My authorization is given voluntarily for the above-stated release of information and will remain in effect for ONE YEAR from the date of signature OR through
Date of Signature

MonthDayYear
Date
Signature*

Clear
UAF is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.
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Student Health and Counseling Center