Page 1 of 2
Emergency Contact and Medical Form - Techscaler New York & New Jersey 2026
Please complete this form by
12 noon
Monday 6th April.
Your answers to this form can only be accessed by the following CodeBase Team Members, to ensure the delivery of the programme:
- Anaïs Guillemaud, Head of International
- Jennifer Forbes Iannolo, VP of Business Acceleration Programmes
- Jessica McClure, Programme Manager
- Debbie Baird, IT Manager
- Accompanying Programme Manager(s)
The answers you submit in this form will be collected via Tally and stored on Google Drive and deleted by September 2026, following the completion of the Techscaler New York and New Jersey Programme.
Your full name
*
Your email address
*
Your phone number.
*
Do you have any medical and/or accessibility information you'd like us to know?
*
Your emergency contact's name
*
Your emergency contact's relationship to you
*
Your emergency contact's phone number.
*
Is there anything else we should know about your emergency contact?
Submit
