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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.

* Child's Name

* Child's Date of Birth

Emergency Contact #1

* Contact Name

* Home Phone Number

* Cell Phone Number

* Work Phone Number

Emergency Contact #2

* Contact Name

* Home Phone Number

* Cell Phone Number

* Work Phone Number

Emergency Contact #3

* Contact Name

* Home Phone Number

* Cell Phone Number

* Work Phone Number

Emergency Contact #4

* Contact Name

* Home Phone Number

* Cell Phone Number

* Work Phone Number

Account Details

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

*E-mail

*First Name

*Last Name

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

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

Total:

ELC Emergency Card

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

Credit Card

Checking Account

For added Security please check the box below.

ELC Emergency Card

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

Credit Card

Checking Account

For added Security please check the box below.

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