Student Emergency Contact Form Template

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Student Emergency Contact Form Template

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Help us ensure the safety and well-being of our students by providing your emergency contact information. All information collected in this survey will be kept confidential and used only in the event of an emergency involving the student.

*

1.

Student's full name:

*

2.

Student's home address:

*

3.

Emergency contact name:

*

4.

Emergency contact relationship to student:

Father

Mother

Sibling

Grandparent

Other (please specify)

*

*

5.

Emergency contact phone number:

*

6.

Emergency contact email address:



*

7.

Is there a secondary emergency contact?

Yes

No

*

8.

Secondary emergency contact name:

*

9.

Secondary emergency contact relationship to student:

Father

Mother

Sibling

Grandparent

Other (please specify)

*

*

10.

Secondary emergency contact phone number:

*

11.

Secondary emergency contact email address:



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