Employee Emergency Contact Information

Michigan STEM Preschool, Inc., 29633 Ford Rd, Garden City, MI 48135
License No. DC824026313, Wayne County

Complete all applicable fields. Update this form whenever a contact number or emergency instruction changes.

AEmployee information

Full legal name

Preferred name

Job title

Primary phone

Personal email

BEmergency contacts

Primary emergency contact

Full name

Relationship

Primary phone

Alternate phone

Secondary emergency contact

Full name

Relationship

Primary phone

Alternate phone

CMedical and emergency information (optional)

Preferred hospital

Physician / provider

Provider phone

Other emergency number

Medical conditions, allergies, medications, communication needs, or emergency instructions

DEmployee authorization

In an emergency, call 911 first when appropriate. I authorize Michigan STEM Preschool, Inc. to contact the individuals listed above and to share information reasonably necessary to obtain emergency assistance for me.

I agree to the authorization above.

Employee signature (type your full name)

Date

Annual review, no changes Information updated

Employee initials

Back to the website

Confidential personnel record. The office stores it securely in your employee folder and reviews it at least once a year.