Bon Homme School District #04-2 Employee Emergency Contact Form
Name: ______________________________________________________________________________________________________
Home Address: _______________________________________________________________________________________________
City: ____________________________________________ State: __________ Zip: _______________
Home Phone #: ___________________________________ Cell Phone #: ___________________________________
Home E-Mail Address: ________________________________________________________________________________________
Emergency Contact #1:
Name: ______________________________________________________________________________________________________
Home Address: _______________________________________________________________________________________________
City: ____________________________________________ State: __________ Zip: _____________
Home Phone #: ___________________________________ Cell Phone #: ___________________________________
Emergency Contact #2:
Name: ________________________________________________________________________________
Home Address: _________________________________________________________________________
City: ____________________________________________ State: __________ Zip: _____________
Home Phone #: ___________________________________ Cell Phone #: ___________________________________
Do you give us permission to transport you to the nearest medical facility should you incur serious illness or injury during normal work hours?
Circle: Yes No
If yes, please indicate the name and contact telephone number of the physician or health care provider that you would like for us to contact:
Name: ______________________________________________________________________________________________________
Hospital/Clinic: ______________________________________________________________________________________________
Phone: _____________________________________________________________________________________________________
Are you allergic to any medications? (please list) _________________________________________________________________
___________________________________________________________________________________________________________
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