Emergency Contact Form
(to be completed as part of an International Student's application packet - this form must be completed!) 

Please print this form, complete it and fax to the Admissions office.  Fax number is 417.659.4429.

Student's First Name ________________________

Student's Last Name ________________________

Part A: In case of emergency (list someone in the US we could contact)

Contact's First Name _________________________

Contact's Last Name _________________________

Contact's Email Address ______________________

Contact's Permanent Mailing Address: 

Street ______________________________________ 

State __________ City _________________________ 

Zip Code __________ Country ___________________

Contact's Telephone:

Day: Country code (if outside US) _______________________

Evening: Country code (if outside US) _______________________

Part B: In case of emergency (list your next of kin from your country)

Kin's First Name _________________________

Kin's Last Name _________________________

Address 

Street ___________________________________

City ___________ State _____________Zip ______________

Telephone

Day:  Country Code ______Phone _________________________

Evening:  Country Code _______Phone _____________________

Please mail or fax this form to:                                                                                       

Missouri Southern State College/Admissions

3950 E. Newman Road

Joplin, MO 64801

Fax: 417-659-4429