XLU Emergency Contact Form

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100% of survey complete.

This form is designed to help us more quickly inform family members of your safety in the event of an emergency. Please complete the information as thoroughly as possible. All information provided will be kept confidential. We will not disclose your personal information to a third party without your consent, unless we are required or authorized to do so by law or other regulation.

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* 1. Your Personal Information

Full Name

Cell Phone

Wechat

Passport No.

Your University

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* 2. Your Program

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* 3. Program Duration

From

Date

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* 4. Primary Emergency Contact Information

Name

Relationship

Home phone

Cell phone

Work

City

Address

Zip code

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* 5. Secondary Emergency Contact Information

Name

Relationship

Home phone

Cell phone

Work

City

Address

Zip code

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* 6. Alternate Emergency Contact Information (if applicable)

Name

Relationship

Home phone

Cell phone

Work

City

Address

Zip code

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* 7. How would you like to pay for your "行前教学指导"(700RMB)?

Pay with Alipay

Pay with WeChat Pay

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📱Scan one of the following QR codes📱

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Do not hit "Submit" button
until you've finished your payment