Emergency Contact Form - Unm Continuing Education
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1Course #:_____________
UNM Continuing Education Youth Programs
Semester: ____________
EMERGENCY CONTACT FORM/PARENTAL PERMISSION
Student Name: __________________________________ Date of Birth: _____________ Gender: ________
_______________________________________________________________
Student Address:
Street Address
City
State
Zip
Emergency Contacts: (Required)
Please list at least 3 individuals who may be contacted in case of emergency.
Name
Phone
Relationship to Student
1.
2.
3.
Authorized Pick-Up List: (if not included on Emergency Contact list)
Please list up to 3 individuals who are authorized to pick up the student. Persons not listed below WILL NOT be permitted to pick up
the student without written permission from a parent or guardian.
Name
Phone
Relationship to Student
1.
2.
3.
Medical Conditions/Allergies: (Required)
List any medical conditions of the participant, including medications currently taking and known allergies.
Medical Condition(s):
Medication/Dosage:
With Child?
YES / NO
YES / NO
YES / NO
Allergies:
Describe reaction:
Severity?
LOW/MED/HIGH
LOW/MED/HIGH
LOW/MED/HIGH
I verify that all the information provided above is correct and complete. I realize that participation involves an
inherent potential risk. In the event of an emergency, I authorize the University of New Mexico Division of
Continuing Education staff to make arrangements as reasonably necessary to ensure my child’s welfare.
I authorize the use of my child’s image to be used in program and marketing materials
YES
NO
________________________________________
________________________________________
________________
Signature of Parent/Guardian
Print Parent/Guardian Name
Date
________________________________________
________________________________________
Parent/Guardian Phone (circle: work / home / cell)
Parent/Guardian Phone (circle: work / home / cell)
Student Information: (optional)
This optional additional information will not be linked to your student’s name, and will help us to improve our future programs.
What school does the student attend / or are they homeschooled?
What grade is the student in?
What is the student’s favorite subject in school?
How would you describe the student’s racial/ethnic background?
505-277-0698
ce.unm.edu/youth
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