Randolph College - ICE Form

ICE Form

In Case of Emergency (ICE) Form

The International Students Office needs to know whom to contact In Case of an Emergency (ICE). Please list contact information for your home country and for the USA (if you have that).

Please tell us about yourself:

Gender:	Male: Female:
*Family Name (Last Name)
*First Name
*School Email Address
Country of Citizenship
Native Language
Date of Birth
Graduation Year
Religion
SEVIS Number
*Home Country Telephone	(Note: Please Include Country Code)
Cellular Phone (if applicable)

Home Country Address: (Please enter the address as it would appear on a mailing envelope).

Address Line 1
Address Line 2
Address Line 3 (City, Prov., Code)
Country

Health Insurance Information:

Health Insurance Company
Company Phone Number
Policy Number

A. In Case of Emergency, name of someone we can contact in your home country :

Gender:	Male: Female:
Family Name
First Name
Relationship to you?
Contact's Home Telephone
Contact's Address Line 1
Contact's Address Line 2
Contact's Address Line 3
Contact's Country
Does this person speak English?	Yes No
If NO - Language(s) Spoken

B. In Case of Emergency, name of someone we can contact in the United States :

Gender:	Male: Female:
Family Name
First Name
Relationship to you?
U.S. Contact's Telephone
Address Line 1
Address Line 2
Address Line 3 (City, State, Zip )
Does this person speak English?	Yes No
If NO - Language(s) Spoken

ICE Form

Thank You