Emergency Contact Information Form

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EMPLOYEE AND EMERGENCY CONTACT INFORMATION FORM
EMPLOYEE NAME:_______________________________________ DATE:______________
PROGRAM/WORK LOCATION: __________________________________________________
HOME ADDRESS: _____________________________________________________________
BEST CONTACT NUMBER FOR YOU (EMPLOYEE):
_____________________ (____HOME _____ CELL)
ALTERNATE CONTACT NUMBER FOR YOU (EMPLOYEE):
_______________________ (____HOME _____ CELL ____ OTHER)
BEST E-MAIL CONTACT ADDRESS FOR YOU (EMPLOYEE):
_____________________________________________________________
IN CASE OF AN EMERGENCY PLEASE CONTACT:
PRIMARY EMERGENCY CONTACT NAME: ______________________________________________
RELATIONSHIP TO EMPLOYEE:_________________________________________________________
PRIMARY EMERGENCY CONTACT ADDRESS: ___________________________________________
BEST # TO REACH EMERG. CONTACT: ___________________________
( __HOME __ CELL ___WORK)
ALTERNATE NUMBER AND/OR E-MAIL ADDRESS FOR EMERGENCY CONTACT
:
_____________________
: _______________________________
(___HOME __ CELL ___WORK)
E-MAIL
ND
2
EMERGENCY CONTACT
NAME:_________________________________RELATIONSHIP TO EMPLOYEE__________________
nd
BEST #(s) TO REACH 2
EMERGENCY CONTACT: ________________________________________
I,__________________________________, understand that by providing emergency contact information I
am authorizing Eden II to contact any of the above individuals if there is ever an emergency or perceived
emergency during the course of my employment.
Please reach out to HR anytime you would like to change your emergency contact information, or have a change in
address or personal contact info. Thank you!

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