Emergency Contact Form - Atlantic Language School Galway

Emergency Contact Details Form

ABOUT THIS FORM

We ask you to complete the details on this form so that we have important information about you in case you have an emergency, an accident or have any difficulties while you are a student at Atlantic Language. We do not expect that we will need to use it, but we want you to feel comfortable and safe while you are attending this school, knowing that if you have an emergency we will be able to contact the people who are important to you and give essential information to doctors if necessary. If any of the information changes while you are here, please let us know.

Your Personal Contact Details

First Name *

Example: MARIA LUISA

Family Name *

Example: SANTOS

Date of Birth *

DD/MM/YYYY

SID (Student Identification Number) *

Example: G123456

Mobile Phone Number *

Please provide an accurate mobile phone number. Include the international code (+353 86 1234567)

Email Address *

Example: [email protected]

Address in Ireland *

Please provide your current address in Ireland

Home Address *

Please provide your address in your home country

Emergency Contact Person Information

Please provide contact details for a family member or a person you are close to, that we can contact if you have an emergency and are not able to contact them yourself.

Name of your Emergency Contact Person *

Example: MARTA GONZALEZ

Relationship * Relationship

What is your relationship with this person? (example: father, sister, partner, etc)

Mobile Phone Number of your Emergency Contact Person *

Please provide an accurate mobile phone number. Include the international dialling code. (Example: +34 602 12 34 567)

Email Address of your Emergency Contact Person *

Example:[email protected]

Language *

Please let us know which language(s) your Emergency Contact Person speaks

Address of your Emergency Contact Person *

Please provide a complete address for your emergency contact person. Include the country of residence and a postcode

Emergency/ Medical Information

You do not have to give us this information if you do not want to. We will respect your decision. Any information you provide here will be kept safely and we will destroy it when you finish your course.

Do you have any medical conditions or allergies that a doctor/medical professional should know about in an emergency? If yes, you can provide details here:

Is there any other information you think we should know in case of an emergency?

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