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Staff Emergency Card | 2022-2023
Every employee must complete this each year. All information will be kept confidential.
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Date of Birthday
*
MM
/
DD
/
YYYY
Best Phone Number
*
Your answer
Address: House # & Street
*
Your answer
Address: City
*
Your answer
Address: Zip Code
*
Your answer
Car: Make/Model
*
Your answer
Car: Color
*
Your answer
Car: License Plate #
*
Your answer
Emergency Contact #1 - Name (First & Last)
*
Your answer
Emergency Contact #1 - Relationship to You
*
Your answer
Emergency Contact #1 - Best Contact Number
*
Your answer
Emergency Contact #2 - Name (First & Last)
Your answer
Emergency Contact #2 - Relationship to You
*
Your answer
Emergency Contact #2 - Best Contact Number
*
Your answer
Known Medical Condition(s)
*
Your answer
Known Allergies
*
Your answer
Medication(s) Taken
*
Your answer
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