Fillable EMERGENCY CONTACT INFOMATION (Weatherford College)

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EMERGENCY CONTACT INFOMATION (Weatherford College)

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File type: PDF

U.S.A. forms for Weatherford College

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Weatherford College Upward Bound
EMERGENCY CONTACT INFOMATION
All information provided will be strictly confidential
Student Contact Information:
Student’s Last Name
Student’s First Name
Middle Int.
Student’s Cell Number
Physical Address (include apt. #)
Date of Birth
City
Zip Code
Mailing Address if different from above
Zip Code
City
VW&RQW
act 3DUHQW*XDUGLDQInformation:
Parent/Guardian Last Name
First Name
Middle Int.
Relationship to Student
Cell Number
Home Number
Work Number
Physical Address (include apt. #)
City
Zip Code
Mailing Address if different from above
City
Zip Code
2
nd
Contact3DUHQW*XDUGLDQ Information:
Parent/Guardian Last Name
First Name
Middle Int.
Relationship to Student
Cell Number
Home Number
Work Number
Physical Address (include apt. #)
City
Zip Code
Mailing Address if different from above
City
Zip Code
Weatherford College Upward Bound
EMERGENCY CONTACT INFOMATION
In the event that Upward Bound Staff cannot reach the guardian(s), the following person(s) should be contacted:
Contact’s Last Name
First Name
Middle Int.
Relationship to Student
Cell Number
Home Number
Work Number
By electronically initialling in the box, I give the above person permission to pick up or drop off my child.
Contact’s Last Name
First Name
Middle Int.
Relationship to Student
Cell Number
Home Number
Work Number
By electronically initialling in the box, I give the above person permission to pick up or drop off my child.
Contact’s Last Name
First Name
Middle Int.
Relationship to Student
Cell Number
Home Number
Work Number
By electronically initialling in the box, I give the above person permission to pick up or drop off my child.
Family Physician
Name of Family Physician
Address
Phone Number
Student’s Health Insurance Information
Name of Insurance Company
Insurance Phone #
Policy Number
Name of Insured
Insured DOB
Group Number
NOTICE: Student’s insurance will be filed first, then WCUB insurance will be filed as secondary. All cost NOT
covered by insurance, will NOT be the responsibility of the student’s family.
Consent
It is understood that consent is given in advance of any emergency, diagnosis, or treatment required while the student is
participating in Upward Bound activities and, that this Medical Release Form authorizes designated school personnel to
exercise their best judgement should action be warranted to ensure student’s safety, life, and health.
I hereby authorize the medical examination and/or treatments deemed necessary by the attending
physician for accidents or illness while participating in Upward Bound. Notify me and/or person(s) listed
above as soon as possible.
I do NOT permit medical treatment until I have been contacted.
Signature of Parent/Guardian
Date
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EMERGENCY CONTACT INFOMATION (Weatherford College)

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Completed 7 October 2020

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