HTML Preview School Employee Emergency Notification Form page number 1.
2016-2017
SCHOOL DISTRICT OF MAUSTON EMPLOYEE EMERGENCY NOTIFICATION FORM
To Be Completed the ANNUALLY
EMPLOYEE’S NAME:
HOME ADDRESS: PHONE:
SPOUSE’S NAME: WORK PHONE:
SPOUSE CELL PHONE: _________________ YOUR CELL #: _____________________
EMERGENCY CONTACT NAMES (WHEN SPOUSE CANNOT BE REACHED):
1. PHONE:
2. PHONE:
FAMILY PHYSICIAN: PHONE:
SIGNATURE OF EMPLOYEE DATE
EMERGENCY INSTRUCTIONS
IN CASE OF EMERGENCY PLEASE DO THE FOLLOWING:
PLEASE CIRCLE APPROPIATE HEALTH CONCERN(S) – EXPLAIN FURTHER BELOW, IF NECESSARY:
VISION - HEARING - ASTHMA - DIABETES - SEIZURES - HEART - OTHER
ALLERGIES:
ACTIVITY OR DIET RESTRICTIONS:
REGULAR MEDICATIONS USED: