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EMERGENCY CONTACT FORM - DOC

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					                                EMERGENCY CONTACT FORM
                      Bethel University Association Clubs & Organizations
                                       Bethel University
                                                                                    Date ______________
Student Name:________________________________________________________

Address:_____________________________________________________

City: _______________________________ State: ________ Zip: _______________

Cell Phone: ________________

In Case of an Emergency, Please Contact:

Name:_______________________________ Relationship ____________________

Work Phone:________________________ Home Phone: _____________________

Address:_______________________________________________________________

City:________________________________ State________ Zip:_________________

Parent or Legal Guardian(s):

Mother/Father/Guardian(s):_______________________________________________________

Address: ______________________________________________________________

City: _______________________________ State: ________ Zip: _______________

Work Phone: ___________________________ Home Phone:__________________

Do you live on campus? Yes ⃞       No ⃞
If yes, where do you live and who is your RD? ____________________________________

          This Information Is To Be Filed in the Student’s Record and Used Only For Emergencies

				
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posted:5/26/2011
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Jun Wang Jun Wang Dr
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