Staff Emergency Form
Please fill out the information below in case of an emergency
Date *
MM
/
DD
/
YYYY
First Name *
Your answer
Last Name *
Your answer
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
Your answer
Home phone number
Your answer
Cell phone number
Your answer
Emergency Contact - Name
Your answer
Emergency Contact - Relationship
Your answer
Emergency Contact - Home Phone
Your answer
Emergency Contact - Cell Phone
Your answer
Physician name and phone number
Your answer
Preferred hospital
Your answer
Facts concerning my medical history
Your answer
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
Follow these procedures
Your answer
Submit
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