Emergency Data
In order to deal effectively with personal emergencies and possible disasters, Carlmont must develop a plan to contact friends or family members of staff and volunteers on site in case of an emergency.

For this reason, the Carlmont Administration is requiring staff to complete this emergency data sheet.  This information is confidential.
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Staff / Volunteer *
Last Name *
First Name *
Telephone # (W) *
xxx-xxx-xxxx
Telephone # (H) *
xxx-xxx-xxxx
Telephone # (Cell) *
xxx-xxx-xxxx
Home Address *
City *
Zip Code *
Classroom # *
Date of Birth (MM/DD/YY) *
If 911 is called, they will as for a date of birth.
#1 Emergency Contact Last Name *
#1 Emergency Contact First Name *
#1 Emergency Contact Relationship *
#1 Emergency Contact Telephone # *
xxx-xxx-xxxx
#1 Emergency Contact Cell Phone # *
xxx-xxx-xxxx
#2 Emergency contact Last Name
#2 Emergency Contact First Name
#2 Emergency Contact Relationship
#2 Emergency Contact Telephone #
xxx-xxx-xxxx
#2 Emergency Contact Cell Phone #
xxx-xxx-xxxx
#3 Emergency Contact Last Name
#3 Emergency Contact First Name
#3 Emergency Contact Relationship
#3 Emergency Contact Telephone #
xxx-xxx-xxxx
#3 Emergency Contact Cell Phone #
xxx-xxx-xxxx
Special consideration during an emergency (i.e. medication(s) you are taking, allergies, allergies to medications, etc.)
Physicians Name *
Physicians Telephone # *
xxx-xxx-xxxx
Do you have any special disaster preparedness training (e.g. American Red Cross Disater Preparation).  Include actual experience, if any:
CPR Expiration Date: (MM/YY)
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