Emergency Contact - Poland Presbyterian Church

The following information will be stored in the church data base for office use only. Your emergency contact(s) can be adult children, neighbors or friends.

* Indicates required field

Your Name *

First

Last

Contact #1 Name *

First

Last

Contact 1 Phone # *

Relationship to You *

Emergency Contact #2 Name *

First

Last

Contact 2 Phone # *

Relationship to You *

Submit