Employee Emergency Medical Care:
Check all schools you work in:
By submitting this form to the Health Service's office, I hereby give my permission to call on the following medical services in the event of an emergency: Seymour/Black Creek Rescue Squad.
List any special health conditions (i.e. diabetes, allergies, etc.) or type none.
In case of emergency please notify:
Home Phone/Cell Phone:
* Enter Your Email Address: