Employee Emergency Contact Form Please fill out and submit this form. * – Required field. Employee Name:* First Last Personal Contact InfoHome Phone: Area Code - Phone Number Home Address:* Street AddressCityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState / Province / RegionPostal / Zip CodeEmergency Contact InfoCell Phone Area Code - Phone Number Name (1): First Last Relationship (1):Home Phone (1): Area Code - Phone Number Cell Phone (1): Area Code - Phone Number Medical InfoName (2): First Last Relationship (2):Home Phone (2): Area Code - Phone Number Cell Phone (2): Area Code - Phone Number Any allergies or Medical Condition relevant to work environment::NONEChoose one option belowI have voluntarily provided the above contact information and authorize York Manor Swim Club and its representatives to contact any of the above on my behalf in the event of an emergencyAGREEDISAGREEI choose not to furnish any emergency contact information to York Manor Swim Club at this time.CONFIRMSignature(s)Employee Signature (typing my name constitutes a signature):*Parent/Guardian Signature if employee is under 18 (typing my name constitutes a signature):SubmitReset
