Emergency Notification Form
Revised 7/27/11
IN CASE OF AN EMERGENCY OR ACCIDENT, LINCOLN TRAIL DISTRICT HEALTH
DEPARTMENT SHOULD CONTACT THE FOLLOWING:
Name: ________________________________________
(relationship)
Address: ________________________________________
City/State/Zip: ________________________________________
Cell Phone Number: ________________________________________
Work Phone Number: ________________________________________
Home Phone Number: _________________________________________
OR
Name: ________________________________________
(relationship)
Address: ________________________________________
City/State/Zip: ________________________________________
Cell Phone Number: _________________________________________
Work Phone Number: _________________________________________
Home Phone Number: _________________________________________
_____________________________ ________________________________
Employee Printed Name Employee Signature (date)