Emergency Notification Form


I hereby authorize the University of Virginia, Information Technology & Communication to notify the below listed person(s) in case of serious accident, injury or illness occurring to me while on University premises.

 

Primary Contact ________________________________________________

Address: ______________________________________________________

Relationship ___________________________________________________

Home Telephone _______________________________________________

Work Telephone _______________________________________________

 

Alternate Contact _______________________________________________

Address _______________________________________________________

Relationship ___________________________________________________

Home Telephone ________________________________________________

Work Telephone ________________________________________________

 


Employee Signature ______________________________________________

Employee Name _________________________________________________

 

Forward completed form to ITC Human Resources Manager, ITC Carruthers Hall

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