PICKENS COUNTY SCHOOLS COOP EMERGENCY CONTACT FORM 2021-2022

PICKENS COUNTY SCHOOLS

Work-Based Learning Program
Proof of Insurance and Emergency Contact Form
School year
Insurance Information

Please note the student's health insurance coverage below:
Name of Insurance Plan:
Insurance Card ID/Policy #
Expiration Date:

Month Day Year
Date
Please attach a photocopy of Health Insurance Card, Drivers License, and Current Auto Insurance proof (on the automobile student will be driving to work). Preferred all on one sheet of paper together.

Emergency Contact Information

Please provide the name, address, and telephone number of two persons who may be contacted in the event of an emergency:
Name and Relationship of Person #1:
Street Address:
City, State, and ZIP Code
Phone Number:
Cell Phone Number:
Email Address:
example@example.com
Name and Relationship of Person #2:
Street Address:
City, State, and ZIP Code
Phone Number:
Cell Phone Number:
Email Address:
example@example.com
Name of School:
Please upload a copy of your health insurance card, drivers license, and current auto insurance proof

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PICKENS COUNTY SCHOOLS