Birthdate: Month: _____ Day: _____
EMPLOYEE EMERGENCY CARD Fairfield-Suisun Unified School District
Name: ____________________________________________________________ Social Security Number: ________________________________
School(s): ______________________________________________________________________ Position: ________________________________
Home Address: __________________________________________________________________ Telephone: ______________________________
(Street Address) (City) (Zip Code)
Date of Birth: ____________________________________________ Email: ______________________________________________________________________
Specialized Health Problems: _________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Wear Glasses? ( ) Yes ( ) No Contact Lens? ( ) Yes ( ) No Taking any medication? ( ) Yes ( ) No
If taking medication, indicated nature of medication: _____________________________________________________________________________
Check your medical coverage plan: ( ) Kaiser I.D. # ____________________________
( ) Other ___________________________________ I.D. # ____________________________
IN CASE OF EMERGENCY, please notify: _______________________________________________________________________________________
(Name) (Relationship)
__________________________________________________________________________________________________________________________
(Address) (Telephone)
Physician (Name and Address): _______________________________________________________________________________________________
In an emergency, due to serious illness or accident, when the above cannot be contacted, the Fairfield-Suisun Unified School District
authorities have my permission to use their best judgment in the interest of my health.
________________________________________________________________________________ ________________________________________
(Signature of Employee) (Date)
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