We're No Different Home Health Agency

Emergency Contact Information

Please complete this form in its entirety. This information will be used only in the event of an illness, injury, or emergency while you are working or representing We’re No Different, LLC.

EMPLOYEE INFORMATION

Employee Name: *

Position: *

PRIMARY EMERGENCY CONTACT

Name: *

Relationship: *

Primary Phone Number: *

Secondary Phone Number (Optional):

Address (Optional):

SECONDARY EMERGENCY CONTACT (Optional)

Name:

Relationship:

Primary Phone Number:

Secondary Phone Number (Optional):

Address (Optional):

AUTHORIZATION

I authorize We’re No Different, LLC to contact the individual(s) listed above in the event of an illness, injury, medical emergency, or other situation requiring notification while I am working or representing the agency. I understand it is my responsibility to notify We’re No Different, LLC of any changes to this information.

Employee Signature: *

Date: *