EMERGENCY CONTACT FORM

OVERTON INDEPENDENT SCHOOL DISTRICT EMERGENCY CONTACT FORM

This information will be extremely important in the event of an accident or medical emergency.
Employee's Name
Emp ID#
Emergency Contacts (2)
Name #1
Phone #1
Format: (000) 000-0000.
Name #2
Phone #2
Format: (000) 000-0000.
Primary Care Physician
Contact number
Preferred Local Hospital
Insurance Information
Company
Policy #
Comments: (include any special medical or personal information or current medications you would want an emergency care provider to be aware of, including allergies)
Employee Signature

Clear
Date

MonthDayYear
Date
A copy of this form is on file with the School Nurse
Should be Empty:

Emergency Contacts (2)