Employee Emergency Contact Form
Name________________________________________________________________________________
Assigned School________________________________________________________________________
Signature ____________________________________ Date ____________________________________
Personal Contact Information:
Home Address_________________________________________________________________________
City, State, ZIP_________________________________________________________________________
Home Telephone #_________________________________ Cell # _______________________________
Emergency Contact Information:
(1.) Name__________________________________Relationship_________________________________
Address______________________________________________________________________________
City, State, ZIP_________________________________________________________________________
Home Telephone#_______________________________ Cell #__________________________________
Work Telephone #_______________________________ Employer_______________________________
(2.) Name_____________________________________________________________________________
Address______________________________________________________________________________
City, State, ZIP_________________________________________________________________________
Home Telephone #_______________________________ Cell # _________________________________
3335 South Beech Daly Road
Dearborn Heights, Michigan 48125
313-565-1900
Working Together to Prepare Students to Succeed in a Competitive Society