Emergency Contact Form

Name ____________________________________________ Date _________________

Home Address _______________________________________________________________

City, State, ZIP _______________________________________________________________

Home Telephone # ___________________________ Cell # _______________________

Emergency Contact Info

(1) Name _________________________________________ Relationship ____________

Home Address _______________________________________________________________

City, State, ZIP _______________________________________________________________

Phone # ________________________________ Work # ___________________________

(2) Name ________________________________________ Relationship ____________

Home Address _______________________________________________________________

City, State, ZIP _______________________________________________________________

Phone # ________________________________ Work # ___________________________

Medical Info

Doctor Name __________________________________ Phone # ____________________

Preferred Hospital ____________________________________________________________

Allergies ____________________________________________________________________

Medical Alert(s) _______________________________________________________________

☐ I have voluntarily provided the above contact information and authorities (Company Name
Here) and its representatives to contact any of the above on my behalf in the event of an
emergency.

Employee Signature ____________________________________ Date ______________