Carlmont High School Emergency Data Sheet

In order to deal effectively with personal emergencies and possible disasters, Carlmont must develop a plan to contact friends or family members of staff and volunteers on site in case of an emergency

For this reason, the Carlmont Health Aide is requiring all staff to complete this emergency data sheet. This information is confidential and is kept only in the Health Office.

* Required

Staff / Volunteer *

Certificated
Classified
Volunteer

Last Name *

First name *

Telephone # (W) xxx-xxx-xxxx

Telephone # (H) * xxx-xxx-xxxx

Telephone # (Cell) xxx-xxx-xxxx

Home Address *

City *

Zip Code *

Classroom # *

Date of Birth (MM/DD/YY) * If 911 is called, they will ask for a date of birth.

#1 Emergency contact Last Name *

#1 Emergency contact First Name *

#1 Emergency contact Relationship *

#1 Emergency contact Telephone # * xxx-xxx-xxxx

#1 Emergency contact Cell Phone # * xxx-xxx-xxxx

#2 Emergency contact Last Name

#2 Emergency contact First Name

#2 Emergency contact Relationship

#2 Emergency contact Telephone # xxx-xxx-xxxx

#2 Emergency contact Cell Phone # xxx-xxx-xxxx

#3 Emergency contact Last Name

#3 Emergency contact First Name

#3 Emergency contact Relationship

#3 Emergency contact Telephone # xxx-xxx-xxxx

#3 Emergency contact Cell Phone # xxx-xxx-xxxx

Special consideration during an emergency (i.e. medication(s) you are taking, allergies, allergies to medications, etc.)

Physicians Name *

Physicians Telephone # * xxx-xxx-xxxx

Do you have any special disaster preparedness training (e.g. American Red Cross Diaster Preparation). Include actual experience, if any:

CPR Expiration Date: (MM/YY)

First Aid Expiration Date: (MM/YY)

Other Certifications

Hepatitis B Series *

Have you had a Tetanus shot with in the last 10 years? *

Yes
No
I don't know

Other Languages Spoken

Date of Last TB Test (For Volunteers only) MM/YYYY