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Emergency Contact Card
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* Indicates required question
Email
*
Your email
Student Name
*
Your answer
Student ID #
Your answer
Student's Email Address
*
Your answer
Grade
*
Freshman
Sophomore
Junior
Senior
Gender
*
Choose
Female
Male
Date of Birthday
*
MM
/
DD
/
YYYY
Parent/Guardian Name (student resides with)
*
Your answer
Relationship To Student
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Mother
Father
Step Mother
Step Father
Sister/Brother
Grandparent
Aunt
Uncle
Other Relative
Address (include Apt., Borough & Zip Code)
Your answer
Cell Phone
*
Your answer
Home Phone
Your answer
Work Telephone
Your answer
Other Parent/Guardian Name
Your answer
Parent's/Guardian's Email Address
Your answer
Relationship To Student
Choose
Mother
Father
Step Mother
Step Father
Sister/Brother
Grandparent
Aunt
Uncle
Other Relative
Address (include Apt., Borough & Zip Code)
Your answer
Cellphone
Your answer
Home Telephone
Your answer
Work Telephone
Your answer
Other Parent's/Guardian's Email Address
Your answer
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