<p> EMPLOYEE EMERGENCY CONTACT FORM</p><p>Name ______</p><p>Department ______</p><p>Personal Contact Info:</p><p>Home Address______</p><p>City, State, ZIP ______</p><p>Home Telephone # ______Cell # ______</p><p>Emergency Contact Info:</p><p>(1) Name______Relationship______</p><p>Address ______</p><p>City, State, ZIP ______</p><p>Home Telephone # ______Cell # ______</p><p>Work Telephone # ______Employer ______</p><p>(2) Name______Relationship______</p><p>Address ______</p><p>City, State, ZIP ______</p><p>Home Telephone # ______Cell # ______</p><p>Work Telephone # ______Employer ______</p><p>Medical Contact Info:</p><p>Doctor Name. ______Phone # ______</p><p>Dentist Name ______Phone # ______</p><p> I have voluntarily provided the above contact information and authorize Grand Forks County and its representatives to contact any of the above on my behalf in the event of an emergency.</p><p> I choose not to furnish any emergency contact information to Grand Forks County at this time.</p><p>Employee Signature ______Date ______</p>