County of Riverside
ASSESSOR-COUNTY CLERK-RECORDER
EMERGENCY / MEDICAL INFORMATION
Please read the fields carefully and fill out the information. Once you are done, click the submit button to see the pdf file. Please make sure to fill out all required fields with red asterisk next to them.
EMPLOYEE INFORMATION
EmployeeNumber
Last Name
First Name
Middle Name
Address
City
State
Zip
DOB
Home Phone
Cell Phone
Personal E-mail Address
YES
NO
I agree to share my personal phone number for the emergency contact roster in my unit/section.
EMERGENCY CONTACT INFORMATION
Last Name
First Name
Relationship
Cell Phone
Home Phone
Work Phone
Email Address
Last Name
First Name
Relationship
Cell Phone
Home Phone
Work Phone
Email Address
PERTINENT HEALTH INFORMATION (Optional):
Medical Insurance (Plan Name)
(Group # and/or ID #)
Regular Medication:
Misc. (Allergies, Contact Lenses, Dentures, Pacemaker, etc.):