Staff Health Emergency Form

Required

Instructions: Please complete and sign this form and send to Human Resources by clicking submit.
Full Namerequired
First Name
Last Name
Date of Birth (Must contain a date in MM/DD/YYYY format)
Street Address, City, State, ZIP
Phone Number

 

Please list two individuals who can be contacted in case of emergency

 

 

Contact #1

Emergency Contact #1
Relationship
Home Phone
Work Phone
Cell Phone

 

 

Contact #2

Emergency Contact #1
Relationship
Home Phone
Work Phone
Cell Phone

 

 

Health Information

Name of Doctor
Doctor Phone
Name of Hospital Choice
 
I give permission for the school nurse, or other designated PPS employee, to contact the person(s) listed on this information card in the case of an emergency. I understand that this health and emergency information card will be kept confidential and in the nurse's office in my assigned building(s). I further understand that relevant information on this card may be shared with appropriate school personnel and other health care providers as necessary, only in an urgent or emergency situation.
Please type name to sign
Must contain a date in MM/DD/YYYY format

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