Employee Emergency Contact & Medical Info Form

Employee Full Legal Name: ________________________________________

Personal Phone Number: ________________________________________

Home Street Address: ________________________________________

City, State, ZIP: ________________________________________

1. Primary Emergency Contact

Field	Primary Contact Information	Secondary Contact Information
Full Name	___________________________________	___________________________________
Relationship	___________________________________	___________________________________
Primary Phone	___________________________________	___________________________________
Alternative Phone	___________________________________	___________________________________
Email Address	___________________________________	___________________________________

Known Severe Allergies / Medical Conditions: List any medical alerts emergency medical technicians (EMS) should know.

Preferred Medical Facility / Hospital: Designated emergency medical hospital: ________________________________

Verified By (Executive / Department Lead):

Printed Name / Title Date

Attested By (Accountable Participant / Employee):

Printed Name / Role Date