Heart Beats Music SchoolEmployee Emergency Contact Form Employee Information * First Name Last Name Phone * (###) ### #### Email * Line Emergency Contact Information Primary Emergency Contact First Name Last Name Relationship To You * Phone: Primary * (###) ### #### Phone: Secondary (optional) (###) ### #### Email * Line Secondary Emergency Contact (optional) First Name Last Name Relationship To You Phone (Primary) (###) ### #### Phone (secondary, optional) (###) ### #### Email Line Medical Information (Optional). This section is completely optional and will be kept confidential. Please provide any relevant medical information that may be important in case of an emergency. Allergies/Medical Conditions Medications (if applicable): Healthcare Provider Name: Preferred Hospital: Line E-Signature: Date MM DD YYYY Thank you!
