EMPLOYEE EMERGENCY CONTACT FORM
[pic] EMPLOYEE EMERGENCY CONTACT FORM
Name__________________________________________ Department________________________________
Personal Contact Info:
Home Address___________________________________ City, State, ZIP_____________________________
Home Telephone #________________________________ Cell #_____________________________________
Emergency Contact Info:
(1) Name______________________________________ Relationship_______________________________
Address_______________________________________ City, State, ZIP_____________________________
Home Telephone #______________________________ Cell #_____________________________________
Work Telephone #_______________________________ Employer__________________________________
(2) Name______________________________________ Relationship_______________________________
Address_______________________________________ City, State, ZIP_____________________________
Home Telephone #______________________________ Cell #_____________________________________
Work Telephone #_______________________________ Employer__________________________________
Medical Contact Info:
Doctor Name___________________________________ Phone #___________________________________
Dentist Name___________________________________ Phone #___________________________________
*** I have voluntarily provided the above contact information and authorize Wakulla County Clerk of Courts and its representatives to contact any of the above on my behalf in the event of an emergency.
Employee Signature_______________________________ Date______________________________________
*** I choose not to furnish any emergency contact information to Wakulla County Clerk of Courts at this time.
Employee Signature_______________________________ Date______________________________________
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