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Student Emergency Contact Information
1. Emergency Contact Information This form should be completed at the beginning of the community learning placement. All parties should retain a copy of this information to facilitate ongoing communication. Student Information Name of Student: ____________________________________ _______________________ (Semester) (Year) Phone: Email: Community Learning Course: Emergency Contact Name: Daytime Phone: Evening or Cell Phone: Faculty Information Name of Faculty Member: Department Phone: Email: Emergency Contact Name: Daytime Phone: Evening or Cell Phone: Agency Information Name of Agency: Agency Address: Supervisor Name and Title: Phone: Emergency phone Number: Email: Fax: Web Site Address: