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Student Emergency Medical/Contact Information
This emergency contact card must be filled out by every Crown College student. This information is for emergency purposes.
Last Name
First Name
Middle Initial
Insurance Company Provider
Medical Card #
I will be getting insurance through Crown College.
Allergies, Medical Conditions, Special Needs, etc.
Emergency Contacts
Primary Emergency Contact
Last Name
First Name
Middle Initial
Home Phone
Work Phone
Cell Phone
Relationship to the Student
Secondary Emergency Contact
*NOT in the same household as Primary Contact
Last Name
First Name
Middle Initial
Home Phone
Work Phone
Cell Phone
Relationship to Student
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