EMPLOYEE EMERGENCY CONTACT FORM

Name ______

Department ______

Personal Contact Info:

Home Address______

City, State, ZIP ______

Home Telephone # ______Cell # ______

Emergency Contact Info:

(1) Name______Relationship______

Address ______

City, State, ZIP ______

Home Telephone # ______Cell # ______

Work Telephone # ______Employer ______

(2) 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 Grand Forks County and its representatives to contact any of the above on my behalf in the event of an emergency.

 I choose not to furnish any emergency contact information to Grand Forks County at this time.

Employee Signature ______Date ______