SMC FACULTY & STAFF EMERGENCY CONTACT INFORMATION UPDATE FORM

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Welcome to the Santa Monica Emergency Contact Information Form
Please complete the fields below so we may update your information.

Fields indicated by an asterisk must be completed. If the field is not applicable, please enter N/A.

EMERGENCY CONTACT
 

Please provide your emergency contact information .

WHOM SHOULD WE CONTACT IF THE ABOVE PERSON CANNOT BE REACHED?

Please provide an alternate contact  in case your first choice is not available.
ADDITIONAL INFORMATION
ADDITIONAL INFORMATIONYesNo
Do you have any physical problem that we should be aware of at present? *This question is required
If yes, are you under treatment for this physical problem at this time? *This question is required
Do you carry medication with you that you should take? *This question is required
If yes, do you take this medication while at work? *This question is required