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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