Employee Emergency Information
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1
2Employee Emergency Information & Contact Form
This medical information may be necessary in the event of serious illness or accident. Please complete this form accurately and
truthfully. The facts you disclose will be kept confidential and the information provided will be given to others only in an emergency
situation. Please return this form to the Human Resources Department.
Employee Information
Street
Address
Employee Name
City
State & Zip
Social Security #
Date of Birth
Phone #
Cell#
School
Position
Please list a person(s) to contact in case of an emergency:
Primary Contact Person:
Relationship to
Name
that person
Cell #:
Work Phone #:
Secondary Contact Person:
Relationship to
Name
that person
Cell #:
Work Phone #:
Preferred Medical Treatment Person/Location (HR Use Only):
Preferred Doctor
Office #:
Preferred Dentist
Office #:
Preferred Hospital
Office #:
Do you give permission for another doctor or dentist to treat you if preferred doctor is not available?
Yes
No
Middletown City School District
Revised: November 2015
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Parent category: Business