Name & Number of an emergency contact: *
In the event that we need to get a hold of someone we need an emergency contact. With virtual programming this is not likely, but in case we need to keep you safe this is important. Please let us know who this person is to you (Ex: Mom; sibling; etc). If you need us to use a different name when speaking to them (Different from the name you provided in this form) let us know here. If you need to assume a different identity (Ex: Straight Ally; Cis guy) in the event we needed to call let us know here. We never wish to accidentally out someone before their time.