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Emergency Contact Information<br />This form should be completed at the beginning of the community learning placement. All...
Student  Emergency  Contact  Information
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Student Emergency Contact Information

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Students completing course assignments in the community must complete this form and submit it to Community Engagement @ CSUN (SH-443)

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Student Emergency Contact Information

  1. 1. Emergency Contact Information<br />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.<br />Student Information<br />Name of Student: ____________________________________ _______________________<br /> (Semester) (Year)<br />Phone: Email: <br />Community Learning Course: <br />Emergency Contact Name: Daytime Phone: <br />Evening or Cell Phone: <br />Faculty Information<br />Name of Faculty Member: Department <br />Phone: Email: <br />Emergency Contact Name: Daytime Phone: <br />Evening or Cell Phone: <br />Agency Information<br />Name of Agency: <br />Agency Address: <br />Supervisor Name and Title: <br />Phone: Emergency phone Number: <br />Email: Fax: <br />Web Site Address: <br />

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