Staff Emergency Form
Please fill out the information below in case of an emergency
Date *
MM
/
DD
/
YYYY
First Name *
Last Name *
Check box below if you DO NOT have any changes from last year - If checked you DO NOT have to fill out the rest of the form (SCROLL DOWN AND SUBMIT)
Home address
Home phone number
Cell phone number
Emergency Contact - Name
Emergency Contact - Relationship
Emergency Contact - Home Phone
Emergency Contact - Cell Phone
Physician name and phone number
Preferred hospital
Facts concerning my medical history
I do not give my consent for emergency medical treatment, I want the school authorities to TAKE NO ACTION or to follow the procedure below
Clear selection
Follow these procedures
Submit
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