Employee Emergency Contact Form

Name:___________________________________________________________

Department: ___________________________ Date: ______________________

Home Information:

In case of emergencies due to weather conditions:

Home Address:____________________________________________

Home Phone:______________________________________________

Cellular Telephone:_________________________________________

Personal Email Address: ____________________________________

Primary Emergency Contact

Contact Name:____________________________________________________

Relationship to Contact:_____________________________________________

Home Telephone:________________________________________________

Work Telephone: __________________ Cellular Telephone: _________

Email:_________________________________________________________

Secondary Emergency Contact

Contact Name:___________________________________________________

Relationship to Contact:____________________________________________

Home Telephone:_________________________________________________

Work Telephone: __________________ Cellular Telephone: _________

Email:__________________________________________________________

Additional Information (Voluntary)

Allergies (Food, Medication, Insects, Etc.):________________________

_______________________________________________________________

Medical Alert(s):__________________________________________________

_______________________________________________________________