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Series 406P - Emergency Information - Employees

Adopted: August 2000
Revised: December 2015

Home Phone ___________________ ❏ Unlisted Home email_____________________________Cellular_____________________________ Cell Service Provider____________________________
Address ____________________________________________________________________________ City ____________________________ State __________ Zip ________________________
Person to contact in an emergency:
1. (Last name, first name) ________________________________________________________________________________________ Relationship __________________________________________
Home Phone __________________________ Work Phone ___________________________ Cellular _____________________________ Cell Service Provider ______________________________
Address ____________________________________________________________________________ City ____________________________ State __________ Zip _____________________
2. (Last name, first name) ________________________________________________________________________________________ Relationship ________________________________________
Home Phone __________________________ Work Phone ___________________________ Cellular _____________________________ Cell Service Provider ______________________________
Address ____________________________________________________________________________ City ____________________________ State __________ Zip _____________________
Optional:
Pertinent Health Information (severe allergies, etc.) ___________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
In case of serious accident or illness, I hereby authorize Dr. ______________________________________ to give necessary treatment and/or information.
You may call him/her at phone _______________________________
______________________________________ Position__________________________________________
Employee’s Last Name First Middle
❏ Male ❏ Female
Employee #___________________________________________ School/Department_________________________________
To Employee:
Your welfare is our first consideration. In the event of a serious injury or illness at work, the following steps will be taken immediately: the school nurse (if on duty) will be called; emergency line 911
will be called, if deemed necessary, and the person designated on this emergency card will be called. If none of the persons listed can be reached, school personnel will implement emergency procedures
to protect your health.
Please complete this card so we can keep our records up-to-date and initiate emergency care quickly. This information is confidential and may be shared with emergency personnel when necessary.
Your signature acknowledges permission to release information to emergency personnel. If there are any significant changes in your health, please call to keep the school nurse informed.
Date________________ Signature of Employee____________________________________________________

Procedures/406P/12-3-2015