Student Emergency Contact Form - Texas Wesleyan University

Texas Wesleyan Student Emergency Contact Form

Student’s Name ______________________________________

Student’s Cell Phone Number ___________________________

I decline the option to provide emergency contact information.

I will provide emergency contact information. (Complete the information below)

In the event of an emergency, please contact the following individual(s):

Mother or Father (or either guardian)

Mother (or female guardian) only

Father (or male guardian) only

Other

Emergency Contact Information:

Contact Name _______________________________________

Contact Address _____________________________________

___________________________________________________

Contact Home Phone _________________________________

Student Signature:

Contact Cell Phone ___________________________________

____________________________________________________

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Parent category: Business