Employee – Emergency Contact Form

Employee Emergency Contact Form

Please fill out and submit this form.

* – Required field.

Employee Name:*

Personal Contact Info

Home Phone:
Home Address:*

Emergency Contact Info

Cell Phone
Name (1):
Relationship (1):
Home Phone (1):
Cell Phone (1):

Medical Info

Name (2):
Relationship (2):
Home Phone (2):
Cell Phone (2):
Any allergies or Medical Condition relevant to work environment::

Choose one option below

I 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 emergency
I choose not to furnish any emergency contact information to York Manor Swim Club at this time.
Employee Signature (typing my name constitutes a signature):*
Parent/Guardian Signature if employee is under 18 (typing my name constitutes a signature):