2019-2020 SPSP Employee Emergency Information
Email address *
Alternate email address
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First Name *
Your answer
Last Name *
Your answer
Position *
Site *
Cell Phone *
Your answer
Home Phone *
Your answer
Address *
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City *
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Zip Code *
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In case of serious job-related illness or an accident involving me, I hereby authorize school personnel to obtain services of a local doctor and/or ambulance service. Please contact this clinic/hospital: *
Your answer
Doctor Phone Number *
Your answer
In case of serious illness not job-related obtain the services of the following clinic/hospital: *
Your answer
Doctor Phone Number *
Your answer
In case of accident or illness involving me, please contact this person: *
Your answer
Relationship *
Your answer
Cell Phone: *
Your answer
Work Phone: *
Your answer
Home Phone: *
Your answer
If a doctor is not designated above, a physician from the district's panel of doctors will be used. Please write your name to confirm acknowledgement: *
Your answer
A copy of your responses will be emailed to the address you provided.
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