Emergency Contact Sheet printable pdf download

Emergency Contact Sheet

Please print clearly and list emergency contact information that can be reached during HSLI program hours.

Student Name (print name) ___________________________________________________________________________

Student Date of Birth ________________________________________________________________________________

Section I – Personal Information

Student E-mail: _________________ ____________________________________________________________________

Address (Number and Street): _________________________________________________________________________

Apartment No.: ____________City: _______________________State: ____________Zip Code: ____________________

Parent/Legal Guardian Name: _____ ____________________________________________________________________

Relationship to Student: ______________________________________________________________________________

Home Phone: (_________)____________________________________________________________________________

Alternate Phone: (_________)__________________________________________________________________________

Section II – Emergency Contact Information

Emergency Contact 1 – Name: _____ ____________________________________________________________________

Relationship to Student: ________________________________Phone: (________)______________________________

Emergency Contact 2 – Name: _____ ____________________________________________________________________

Relationship to Student: ________________________________Phone: (________)______________________________

40 Washington Square South ● New York, NY 10012 ● ●

Emergency Contact Sheet