# LSJE, LLC

6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel

Fax:

## Emergency Contact Form

Date: 04/09/18
Start Date: <empty>

Employee Name: <empty>
Address: <empty> St. Thomas, VI 00802
Date of Birth: <empty>

Phone: <empty>
Cell: <empty>
E-Mail: <empty>

Title / Position: Housekeeper
Marital Status: Married
License: <empty>

## Emergency Information:

No

Allergies or Health Concerns:<empty>

Blood Type:<empty>

Current Medication:<empty>

Doctor's Name:<empty>
Phone:<empty>

Doctor's Name:<empty>
Phone:<empty>

In case of an Emergency, Please contact :
Name: <empty>
Relationship: <empty>
Phone: <empty>

Name: <empty>
Relationship: Pastor
Phone: <empty>

ThisInformation is for your safety and the safety of others