Emergency Contact Information
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EMERGENCY CONTACT INFORMATION!
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1. Participants’ Name: _______________________________!
2. Date of Birth: _________ !
3. Does the participant live at home? ________!
If no, contact’s name at place of residence:
______________________!
Phone number at residence: ______________________!
4. Parent/Guardian’s address for mailings:
_________________________________________
_________________________________________
Zip Code: ___________!
5. Email address: __________________________________!
6. Does the participant have a legal guardian? ___________ (If no, please
go to #7)!
Guardian’s Name: ____________________________!
Parent’s Name: ______________________________!
Parent/Guardian’s Phone: ______________________!
7. Emergency Contact’s Name: ______________________________!
8. Emergency Contact’s Phone Number: ________________________!
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Please list any special instructions, information, or medical concerns that
may affect successful of safe participation in individual or group activities at
Extraordinary Ventures:!
_________________________________________________________!
_________________________________________________________!
_________________________________________________________!
_________________________________________________________!
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