Staff Emergency Contact Information
2020-2021
Last Name *
First Name *
Birthday (Month/Day/Year) *
E-Number *
Phone Number (Cell & Home) *
Mailing Address *
Make/Model/Color of Car *
License Plate Number *
Emergency Contact Name *
Emergency Contact Phone Number *
Emergency Contact Relationship to Employee *
Family Physician Name *
Physician Phone Number *
Preferred Hospital *
Please list any allergies or medical conditions you may have: *
Employee Signature: In the event that the  person(s) that have been named above cannot be reached, I authorize a campus representative to take me to my family doctor or to the preferred hospital listed above if deemed necessary by the administrative staff. In the event that EMS must be contacted due to a life threatening emergency, I give my consent to be transported to the nearest emergency facility by EMS. (Please type name for signature)
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