Emergency Contact Form

The Health and Safety Committee would like your help in establishing a list of Emergency Contacts for all in our congregation. The purpose of the document is to know whom to contact should one of us experience a medical event while at ACC. Please take a few moments to fill out the information below. This information is kept confidential and will only be used in case of an emergency.

Your Name

First Name

Last Name

Primary Emergency Contact Name

First Name

Last Name

Relationship

Primary Emergency Contact Phone

(###)

###

####

Primary Emergency Contact Email

Secondary Emergency Contact Name

First Name

Last Name

Relationship

Secondary Emergency Contact Phone

(###)

###

####

Secondary Emergency Contact Email

Anything else you would like us to know in case of emergency? Meds? Allergies? Medical issue?