Emergency Contact Form

NCCU Campus Recreation
Student Staff
Personal Information

Please print legibly and return to Campus Recreation front desk staff or e-mail jruther1@eagles.nccu.edu.

Name: ________________________________________________________________

Campus Address: ________________________________________________________

Home Address: __________________________________________________________

Telephone Contact (Campus): _______________________________________________

Telephone Contact (Home/Cell): _____________________________________________

Emergency Contact/ Relationship: ____________________________________________

Campus Rec Position________________________________________________________

Major: ___________________________________________________________________

Where do you plan to be in five years? __________________________________________