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ELC Emergency Card

Medical Emergency Contacts
Please note that all fields are required.  Please list both parents (if applicable) and two additional medical emergency contacts. If a field is not applicable, please type N/A.

Emergency Contact #1

Emergency Contact #2

Emergency Contact #3

Emergency Contact #4

Account Details

Enter your name and e-mail address for your confirmation:

Payment Information

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.
Total: