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) _________________________________________________________________

 

___________________________________________________________________________________________________________

 

_________________________________________________________________________________________