PMB Medical Form

All forms are due August 4, 2025

Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
As of August 9, 2024, I am:

As of August 9, 2024, I am: 18 year old or older Under 18 year old
EIU Email
Personal Email
Gender Identity

Gender Identity Male Female Non-Binary Male to Female (trans woman) Female to Male (trans man)
Campus/Charleston Address Campus/Charleston Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Campus/Cell Phone Campus/Cell Phone - ### - ### ####
Permanent Address Permanent Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact #1 Emergency Contact #1 First Last
Emergency Contact #1 Address Emergency Contact #1 Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact #1 Phone Emergency Contact #1 Phone - ### - ### ####
In the event of an emergency, I give EIU staff, faculty or administration permission to contact Emergency Contact #1. Please enter your name to indicate approval.
Emergency Contact #2 Emergency Contact #2 First Last
Emergency Contact #2 Address Emergency Contact #2 Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact #2 Phone Emergency Contact #2 Phone - ### - ### ####
In the event of an emergency, I give EIU staff, faculty or administration permission to contact Emergency Contact #2. Please enter your name to indicate approval.
Hospital/Clinic Preference
Physician's Name Physician's Name First Last
Physician's Phone Physician's Phone - ### - ### ####
Insurance Company
Policy Number and Group Number
Please list any food allergies.
Please list Non-Food Allergies/Special Health Conditions
List any medications currently being taken
I hereby give Eastern Illinois University and its agents permission to provide this information to health care workers only to facilitate emergency medical treatment.

I hereby give Eastern Illinois University and its agents permission to provide this information to health care workers only to facilitate emergency medical treatment. YES NO
Student's SIgnature
Parent / Guardian Signature (if under 18 years of age)
Today's Date Today's Date / MM / DD YYYY