2015-2016 Student Emergency Contact Form

General Information

The information requested here is confidential and for emergency use only. In the event of a medical emergency, this information will be used by Manhattan School of Music and emergency personnel. Please be honest when completing all pertinent information.

If, at any point, you have questions about completing this form please contact the Student Life at 917-493-4525 or via email at studentlife@msmnyc.edu.

Question Title

* 1. Please enter the following information:

Last Name: *

First Name: *

MSM Student ID: *

Home Address: *

City/Town/Provence: *

State:

ZIP: *

Country: *

Cell Phone: (1-XXX-XXX-XXXX) *

Date of Birth: (MM/DD/YY) *

Question Title

* 2. Please enter your health insurance information below.

My health insurance plan for the 2015-2016 academic year will be:

The MSM sponsored plan

A plan I purchased on my own

My parent's plan

Please provide the name of your insurance plan if it is not the MSM plan:

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* 1. Please enter the following information:

Question Title

* 2. Please enter your health insurance information below.My health insurance plan for the 2015-2016 academic year will be:

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* 3. My health insurance member ID number is:

* 2. Please enter your health insurance information below.

My health insurance plan for the 2015-2016 academic year will be: