Medical Information & Emergency Contact Form Name * First Name Last Name Birthdate * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Emergency Contact Relationship * Secondary Emergency Contact * First Name Last Name Secondary Emergency Contact Phone * (###) ### #### Secondary Emergency Contact Relationship * Do you have any allergies? * Yes No If yes, please describe. Do you require an epipen? * Yes No If yes, please provide details about your anaphylaxis, including the date and description of the reaction: Do you have any dietary restrictions? * Yes No If yes, please provide details about your dietary restrictions: Any other medical information you would like to provide: Medical Waiver * I have disclosed important information about my allergies and/or dietary restrictions. If I have any medical conditions that may affect my ability to complete my job duties, I will discuss them with my direct supervisor. I have read the medical waiver, understand it, and agree to be bound by it. Thank you! We look forward to you joining our team!
