Emergency Contact and Health Information Form

The following required form must be submitted one week prior to the start date of the class.  Please submit one form per participant. You only need to be submit the Emergency Contact and Health Information Form once for the 2021 Summer program.

Required

Participant's Information

Student's Namerequired
First Name
Last Name
Student's Grade (in fall)required
Current Elgin Academy Student?required

 


 

Parent/Guardian Information

Parent/Guardian 1required
First Name
Last Name
Parent/Guardian 2
First Name
Last Name
Who does the student live with?required
Do both parents have campus removal rights?

 


 

Emergency Contact

Primary Emergency Contactrequired
First Name
Last Name
Secondary Emergency Contact
First Name
Last Name

 


 

Transportation & Pick-up

My student will be driving to campus.required
Primary Pick-up Personrequired
First Name
Last Name

 


 

Participant's Heath Information

Student's Doctorrequired
First Name
Last Name