EMERGENCY INFORMATION by wulinqing

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									            FACULTY/STAFF EMERGENCY INFORMATION – YEAR _____________
                                               (Please Print)


Name:                                                                   Department:
            Last Name                            First Name
Address:
Phone Number:                                                   Cell Number:
Doctor:                                                         Preferred Hospital:
Doctor’s Phone Number:
I give permission for the nurse to speak to my physician:
                                                                                  Signature
Pertinent Health Information (optional):


                           PERSONS TO BE CONTACTED IN CASE OF EMERGENCY:
 st
1 Contact Person:                                                       Relationship:
Available during school day at:
Phone Number to call:
Cell Phone Number:
 nd
2     Contact Person:                                                   Relationship:
Available during school day at:
Phone Number to call:
Cell Phone Number:
                                  -- PLEASE RETURN TO HEALTH OFFICE --




            FACULTY/STAFF EMERGENCY INFORMATION – YEAR _____________
                                               (Please Print)


Name:                                                                   Department:
            Last Name                            First Name
Address:
Phone Number:                                                   Cell Number:
Doctor:                                                         Preferred Hospital:
Doctor’s Phone Number:
I give permission for the nurse to speak to my physician:
                                                                                  Signature
Pertinent Health Information (optional):


                           PERSONS TO BE CONTACTED IN CASE OF EMERGENCY:
 st
1 Contact Person:                                                       Relationship:
Available during school day at:
Phone Number to call:
Cell Phone Number:
 nd
2     Contact Person:                                                   Relationship:
Available during school day at:
Phone Number to call:
Cell Phone Number:
                                  -- PLEASE RETURN TO HEALTH OFFICE --

								
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