This form and registration is completely voluntary and confidential. Its sole purpose is to aid emergency personnel in locating a disabled student during an emergency situation that would likely involve a building evacuation. The form will be maintained by the DSS Manager and security personnel in a secure location. You may fill out as much information as you are comfortable with.

Sex
Emergency Contact
Physician Information
The information above is accurate for the semester
I authorize the use and dissemination of this information to authorize personnel for emergency purposes. This form will only be kept on file for the semester(s) you have indicated above, the form will be destroyed after the period you have indicated has expired.