SMC FACULTY & STAFF EMERGENCY CONTACT INFORMATION UPDATE FORM

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

First Name *This question is required.

Last Name *This question is required.

Home Street Address *This question is required.

Apt/Suite

Home City *This question is required.

State

Zip Code *This question is required.

Emergency Contact Email Address *This question is required.

Emergency Contact Phone (Cell or Land-line used for notification of an on-campus emergency) ONLY *This question is required.

Cell Phone *This question is required.

EMERGENCY CONTACT

Please provide your emergency contact information .

First Name *This question is required.

Last Name *This question is required.

Relationship *This question is required.

Address *This question is required.

Apt/Suite/Office

City *This question is required.

State *This question is required.

Zip Code *This question is required.

Cell Phone *This question is required.

Work Phone *This question is required.

Home Phone (Enter work or cellphone number if no other is available) *This question is required.

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

Please provide an alternate contact in case your first choice is not available.

First Name

Last Name

Relationship

Street Address

Apt/Suite/Office

City

State

Zip Code

Cell Phone

Work Phone

Home Phone (Enter work or cellphone number if no other is available)

ADDITIONAL INFORMATION

Space Cell	Yes	No
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

If you take medication while at work, where do you keep this medication?