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Emergency contact information form LLB students
Student number:
*
Last name:
Please mention your full last name, as registered in your passport
*
First names:
Please fill in your full first name(s), as registered in your passport
*
Preferred (first) name:
Please fill in your preferred (first) name
*
Email address:
Please fill in the email address you use most
*
Dutch address: street name and house number:
Please also include your roomnumber if you are living in one of the SSHXL-accommodations
*
Dutch address: postal code and city:
*
Dutch mobile phonenumber:
*
Family name emergency contact:
*
First name emergency contact:
*
Phone number emergency contact:
Please include the country code
*
Email address emergency contact:
*
Relationship to you:
*
Parent
Spouse/partner
Sibling
Friend
Other
Other
Remarks:
I hereby give permission to the International Office of the Faculty Law to use this information in case of emergency:
*
Yes
No
Please indicate why you do not want the International Office to contact your emergency contact in case of emergency:
*
*
=
Input is required