The Emergency Contact Form Template – Canada is offered in multiple formats, including PDF, Word, and Google Docs. Each version is customizable and ready for printing, allowing you to easily tailor it to your requirements.
Emergency Contact Form Template – Canada Editable – PrintableSample
1. Personal Information 2. Emergency Contact Information 3. Additional Emergency Contacts 4. Medical Information 5. Consent for Medical Treatment 6. Signature and Date
PDF
WORD
Examples
[Employee’s Name]
[Employee’s ID]
[Employee’s Address]
[Employee’s Phone]
[Employee’s Email]
[Contact Name]
[Relationship to Employee]
[Contact’s Phone Number]
[Contact’s Email]
[Contact’s Address]
[Contact Name]
[Relationship to Employee]
[Contact’s Phone Number]
[Contact’s Email]
[Contact’s Address]
Please provide any relevant medical information that a responder might need to know in case of an emergency (e.g., allergies, chronic illnesses, medications):
[Medical Information]
[Preferred Hospital Name]
[Hospital Address]
[Hospital Phone Number]
I authorize the disclosure of my personal and medical information to emergency personnel as necessary during a medical emergency.
Signature: ______________________
Date: ______________________
[Employee’s Name]
[Employee’s ID]
[Department]
[Employee’s Phone]
[Employee’s Email]
[Contact Name]
[Relationship to Employee]
[Contact’s Phone Number]
[Contact’s Email]
[Contact’s Address]
[Contact Name]
[Relationship to Employee]
[Contact’s Phone Number]
[Contact’s Email]
[Contact’s Address]
Please list any known medical conditions, allergies, or medications:
[Medical Conditions]
[Insurance Provider Name]
[Policy Number]
[Insurance Phone Number]
I hereby give my consent for emergency personnel to contact my emergency contacts and to provide any necessary medical treatment.
Signature: ______________________
Date: ______________________
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