Emergency Contact Form – Child/Youth

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Emergency Contact

Parent/Guardian's Name(Required)

First Last

In the event of an emergency I give permission to Big Brothers Big Sisters of London & Area to contact the emergency contact as listed below. I also acknowledge that this emergency contact may be called if Big Brothers Big Sisters of London & Area has difficulty connecting with me through traditional means (phone, mail, email, in person, etc.). I understand that Big Brothers Big Sisters of London & Area will not share this emergency contact information with other parties, without my express prior consent where required.

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Emergency Contact Relationship(Required)

Child/Youth's Name(Required)

First Last

Child/Youth's Health Card Number(Required)

Parent/Guardian's Signature(Required)

Date(Required)

By clicking Submit, I consent to the collection of this personal information in accordance with Big Brothers Big Sisters of London and Area's Privacy and Confidentiality Policy.

SMS Verification(Required)