Emergency Contacts Form

Emergency Contacts Form
Please list two emergency contacts. Emergency contacts must be 21 years of age or older. The Learning Abroad Co. may contact these individuals in case of any urgent concern or emergency as determined by The Learning Abroad Co.

I understand that the information shared in an emergency may include sensitive information sucha s health, discipline, or academic information or any other information that would normally be protected by law. I release and authorize the full disclosure of protected information if deemed necessary by The Learning Abroad Co.. In addition, please check the box by each individual’s name if The Learning Abroad Co. has permission to share information regarding your invoice and financial status.
Program Code*
1. Full Name*
Relationship to student*
Phone number?*
Is this a cell, home, or work number?*
2nd Phone number*
Is this a cell, home, or work number?*
Email address*
example@example.com
Physical Address (include street address, city, state, and zip code)*
Do you give permission to The Learning Abroad Co. to contact this person regarding your invoice and financial status?*

YesNo
2. Full Name*
Relationship to student*
Phone number Is this a cell, home, or work number?*
Is this a cell, home, or work number?*
2nd Phone number Is this a cell, home, or work number?*
Is this a cell, home, or work number?*
Email address*
example@example.com
Physical Address include street address, city, state, and zip code*
Do you give permission to The Learning Abroad Co. to contact this person regarding your invoice and financial status?*

YesNo
Name (Printed)*
Name (Signed)*
Signature*

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Email*
example@example.com
Date*

MonthDayYear
Date
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