2020-21 Staff Emergency Medical Form

Employee Emergency Medical

Employee Emergency Medical Form
  • Date Format: MM slash DD slash YYYY
  • Please indicate any facts concerning your medical history, including but not limited to: allergies, medications taken regularly, and any physical impairment in which a physician should be alerted. Please note - All information is confidential and will only be used in case of an emergency.
  • In the event that you become ill or injured at work, we will transport you to Mary Rutan Hospital for immediate care, and the individual below will be notified. Please specify the nearest relative or other person that we should notify in this case.