Family Contact Information Form - Pilgrim Place

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Pilgrim Place Residents’ Family Contact Information Form
Pilgrim Place maintains a list of residents’ children to contact in case of emergency and to
receive periodic invitations to Pilgrim Kin events on campus, the monthly e-Newsletter, and
other Pilgrim Place mailings. Please provide the following information and return this form to
the Pilgrim Place Director of Admission, 625 Mayflower Road, Claremont, CA 91711.
_____________________________________ ______________________________________
Printed name of New Resident
Printed name of Spouse/Partner, if applicable
New Resident Address: __________________________________________________________
City, State, Zip: ________________________________________________________________
Phone Number: ________________________________________________________________
Email: _______________________________________________________________________
▬▬▬
Child’s Name: _________________________________________________________________
Address: _____________________________________________________________________
City, State, Zip: ________________________________________________________________
Phone Number: ________________________________________________________________
Email: _______________________________________________________________________
Receive all mailings ____, or Contact only in an emergency ____.
Child’s Name: _________________________________________________________________
Address: _____________________________________________________________________
City, State, Zip: ________________________________________________________________
Phone Number: ________________________________________________________________
Email: _______________________________________________________________________
Receive all mailings ____, or Contact only in an emergency ____.
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