Emergency Information Form
[Company Name]
Employee Information:
Name:
|
SS#: |
Address:
|
Phone: |
Physician Name: Physician Address:
|
Phone: |
Emergency Contacts:
In the event of an emergency, I, the undersigned employee, authorize [Company Name] to contact the following person(s):
Contact #1 Name:
|
Phone (H):
|
Address:
|
Phone (W):
|
Relationship to Employee:
|
Other method of contact:
|
Contact #2 Name:
|
Phone (H):
|
Address:
|
Phone (W): |
Relationship to Employee:
|
Other method of contact:
|
_________________________________________________________________________________
Employee Signature
________________________
Date