In compliance with the Clery Law, Philadelphia University is providing this form to all resident students for the purpose of identifying a confidential contact person or persons who will be the notified party should the student providing the contact information be determined to be missing. Notification will be made within 24 hours of the student being deemed missing.

This information is confidential, relates only to students determined to be missing, and is not an alternative to any other emergency information provided to Philadelphia University. Only the University’s Office of Safety and Security, police and campus officials involved in the search for a missing student will have access to this information.

STUDENT INFORMATION:   items in bold are mandatory
Student First Name:
Student Last Name:  
Student Cell Phone Number:  
    please enter phone numbers as XXX-XXX-XXXX
Contact's First Name:
Contact's Last Name:  
Contact's Address Line 1:  
Contact's Address Line 2:  
Contact's Home City:  
Contact's Home State:  
Contact's Home Zip Code:  
Contact's Home Phone:
Contact's Work Phone:
Contact's Cell Phone:
    please enter phone numbers as XXX-XXX-XXXX