Form M53 - Emergency Contact Form printable pdf download

Form M53 - Emergency Contact Form

(FORM NO. – M53)

Emergency Contact Form

EMERGENCY CONTACT FORM

Name __________________________________________________________________________

Department _____________________________________________________________________

Personal Contact Info:

Home Address

________________________________________________________________________________

City, State, ZIP ____________________________________________________________________

Home Telephone # __________________________ Cell # _______________________________

Emergency Contact Info:

Name_____________________________________ Relationship________________________

Address ________________________________________________________________________

City, State, ZIP ___________________________________________________________________

Home Telephone # __________________________ Cell # ______________________________

Work Telephone # _____________________ _____ Employer __________________________

Medical Contact Info:

Doctor Name. _____________________________

Phone # ___________________________

Dentist Name _____________________________

Phone # ___________________________

I have voluntarily provided the above contact information and authorize MAGES and its

representatives to contact the above on my behalf in the event of an emergency.

Employee/Student Signature __________________________

Date ______________________________________________

Ver2.0 Dtd. 21/03/2011

Private & Confidential

Form M53 - Emergency Contact Form