rocky channels school system boothbay-boothbay harbor csd
AOS 98 / ROCKY CHANNELS SCHOOL SYSTEM BOOTHBAY-BOOTHBAY HARBOR CSD • EDGECOMB • SOUTHPORT • GEORGETOWN ALL STAFF EMERGENCY INFORMATION UPDATE Print Name: __________________________________________________ School: ___________________________________________ Birth Date: __________________________________ Mailing Address: ______________________________________________________________________________ ______________________________________________________________________________ Physical Address (if different): ______________________________________________________________________________ ______________________________________________________________________________ Phone numbers:
Home _________________ Cell ______________________
Email Address: ___________________________________________________________ Emergency Contacts: Name: ___________________________________ Relationship ________________ All phone numbers: 1._________________________________ 2.___________________________ 3._________________________________ 4.___________________________
Name: ______________________________________ Relationship ______________________ All phone numbers: 1._________________________________ 2. ______________________________ 3._________________________________ 4._______________________________ Allergies: _____________________________________________________________________ Other Information: _____________________________________________________________ _____________________________________________________________________________ Health Care Provider: (Doctor; not insurance) ________________________________ Ph.: ______________ In case of an emergency and we are unable to reach your emergency contact, we will contact the nearest medical facility, if necessary. ________________________________________________ Signature PLEASE RETURN TO OFFICE SECRETARY CENTRAL OFFICE USE ONLY: ADS payroll □
ADS vendor □
NEO □
Directory □
___________________ Date Anthem □ Mainepers □
Home _________________ Cell ______________________
Email Address: ___________________________________________________________ Emergency Contacts: Name: ___________________________________ Relationship ________________ All phone numbers: 1._________________________________ 2.___________________________ 3._________________________________ 4.___________________________
Name: ______________________________________ Relationship ______________________ All phone numbers: 1._________________________________ 2. ______________________________ 3._________________________________ 4._______________________________ Allergies: _____________________________________________________________________ Other Information: _____________________________________________________________ _____________________________________________________________________________ Health Care Provider: (Doctor; not insurance) ________________________________ Ph.: ______________ In case of an emergency and we are unable to reach your emergency contact, we will contact the nearest medical facility, if necessary. ________________________________________________ Signature PLEASE RETURN TO OFFICE SECRETARY CENTRAL OFFICE USE ONLY: ADS payroll □
ADS vendor □
NEO □
Directory □
___________________ Date Anthem □ Mainepers □
