Emergency Contact Form | Penn State York

Emergency Contact Form14.34 KB

Student Information

First and Last Name

Cell Phone Number

Student ID Number

Trip Information

Trip Organizer/Chaperone Email

Trip Location

Trip Date

Emergency Contact Information

List below the name, address, and telephone numbers of at least two people that we may contact in case of an emergency.

Emergency Contact #1

First and Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Home Phone Number

Business Phone Number

Relationship To You

Emergency Contact #2

First and Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Home Phone Number

Business Phone Number

Relationship To You