Emergency Contact Information Form
Student Name (Last):___________________________________ (First):___________________________________________
Please Print
Please Print
Program:
APEA
Architecture
Art & Design
Drama
Music
NHSGA
o
o
o
o
o
o
Address:_______________________________________________________________________________________________
City:______________________________ State:_______________ Zip:_______________ Country:_____________________
Student Cell Phone:________________________________Student Home Phone:__________________________________
Please only submit the student’s cell phone number above. Parent/Guardian cell phone number may be submitted below.
Email Address:____________________________________________________________Citizenship:____________________
Date of Birth: ______________________________________Gender: _____________________________________________
o Resident Student
o Commuter Student
o 3 week student (art & design and architecture)
Parent/Emergency Contact Information
If two parents (or guardians) have custody of student, please list both. In the event of an emergency, the first listed
parent/guardian will be contacted. If that person is not available, the second parent/guardian listed will be contacted.
It is the responsibility of the emergency contact who receives the call to inform anyone else who should be informed.
Parent or Guardian Name:_____________________________________Relationship to student:_____________________
o Address same as above
Address:_______________________________________________________________________________________________
City:______________________________ State:_______________ Zip:_______________ Country:___________________
Home Phone:______________________ Work Phone:_______________________ Cell Phone:_______________________
Email Address:___________________________________________________________
Parent or Guardian Name:_____________________________________Relationship to student:___________________
o Address same as above
Address:_______________________________________________________________________________________________
City:______________________________ State:_______________ Zip:_______________ Country:____________________
Home Phone:______________________ Work Phone:_______________________ Cell Phone:_______________________
Email Address:___________________________________________________________
In the event that neither of the above contacts are reachable/available in a 24-hour period, please provide an alternative emergency contact.
Alternative Emergency Contact:_______________________________Relationship to student:____________________
City:______________________________ State:_______________ Zip:_______________ Country:____________________
Home Phone:______________________ Work Phone:_______________________ Cell Phone:_______________________
Names of any persons other than the above to whom the student may be released or may enter the residence hall
during non-curfew hours (must sign in and out):
_____________________________________________________________________________________________________
If there are dates that NEITHER of the primary emergency contacts will be available, please list below.
_____________________________________________________________________________________________________
2016 Pre-College Forms Booklet
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