Student Emergency Contact Form
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1STUDENT EMERGENCY CONTACT FORM
Student’s Name:
Student ID:
Student’s Current Address:
Student’s Cell Phone Number:
Enroll me in the Text Message Alert System. My Service Provider is:
(e.g. Verizon Wireless, AT&T)
I will provide emergency contact information.
In the event of an emergency, please contact the following individual(s):
1
Contact Name:
st
_________________________________________________________________________________
Last
First
Relationship to Student
Address:
__________________________________________________________________________________________
Street
Town/City
State
Zip
Contact:
__________________________________________________________________________________________
Home Phone
Cell Phone
Email Address
2
Contact Name:
nd
_________________________________________________________________________________
Last
First
Relationship to Student
Address:
__________________________________________________________________________________________
Street
Town/City
State
Zip
Contact:
__________________________________________________________________________________________
Home Phone
Cell Phone
Email Address
Comments or instructions in case of emergency (allergies, medications, medical conditions)
I decline the option to provide emergency contact information.
Student Signature:
Date:
Please return your completed form to your faculty advisor or the Registrar’s Office:
PILLAR COLLEGE | 60 Park Place, Suite 701, Newark, NJ 07102 | T: 973.803.5000 | F: 973.230.3220 | info@pillar.edu |
For office use only:
Date Received:
Date Entered in CV:
Completed by:
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Parent category: Business