Emergency Contact Form for Household Staff Member Justina de la Cruz

EMERGENCY CONTACT FORM

LSJE, LLC 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 Tel: 340-775-8100 Fax: 340-775-8108

Start Date: [blank]

Employee Name: Justina de la Cruz

Address: [REDACTED] Date of Birth: [REDACTED]

Phone: [blank] Cell: [REDACTED] E-Mail: [blank]

Title / Position: Housekeeper Marital Status: Married License: [blank]

Allergies or Health Concerns: NA Blood Type: [REDACTED] Current Medication: [blank]

Doctor's Name: [blank] | Phone: [blank] Doctor's Name: [blank] | Phone: [blank]

In case of an Emergency, Please contact:

1. Name: Feliz de la Cruz | Relationship: Husband | Phone: [REDACTED]

2. Name: Bembenido Gedeno | Relationship: Brother | Phone: [REDACTED]

This Information is for your safety and the safety of others

Names mentioned: - Justina de la Cruz — Employee; Housekeeper employed by LSJE, LLC - Feliz de la Cruz — Emergency contact; Husband of Justina de la Cruz - Bembenido Gedeno — Emergency contact; Brother of Justina de la Cruz