Emergency Information

Student Last Name

Student First Name

Home High School

If other, what is your home high school?

Student Email

Student Cell Phone

Program

Session (required) AM PM

Primary Parent/Guardian First and Last Name

Primary Parent/Guardian Relationship to Student

Primary Guardian/Parent Street Address

Primary Parent/Guardian City

Primary Parent/Guardian State

Primary Parent/Guardian Zip Code

Primary Parent/Guardian Email

Primary Parent/Guardian Home Phone

Primary Parent/Guardian Day Phone

Other Parent/Guardian First and Last Name (if living elsewhere)

Other Parent/Guardian Relationship to Student

Other Parent/Guardian Street Address

Other Parent/Guardian City

Other Parent/Guardian State

Other Parent/Guardian Zip Code

Other Parent/Guardian Email

Other Parent/Guardian Home Phone

Other Parent/Guardian Day Phone

EMERGENCY CONTACT INFORMATION

(Please list in the order of who will be contacted first, second and third in case of an emergency.)

Contact #1 Name

Contact #1 Relationship to Student

Contact #1 Phone Number

Contact #2 Name

Contact #2 Relationship to Student

Contact #2 Phone Number

Contact #3 Name

Contact #3 Relationship to Student

Contact #3 Phone Number

HEALTH ALERT INFORMATION

Please list any health conditions which may need special attention and/or medication(s) used. If dosage is needed during class session, please contact the WTC instructor to make appropriate arrangements.

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