Emergency Contact Form for LSJE, LLC Household Staff Member

EMERGENCY CONTACT FORM

Company: LSJE, LLC Address: 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802 [Phone and Fax redacted]

Start Date: [blank]

Employee Name: Leida Hernandez Address: [REDACTED] Date of Birth: [REDACTED]

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

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

EMERGENCY INFORMATION:

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

Doctor's Name: Coorbin Phone: [REDACTED]

Doctor's Name: Coorbin Phone: [REDACTED]

IN CASE OF AN EMERGENCY, PLEASE CONTACT:

Emergency Contact 1: Name: [REDACTED] Relationship: Married Phone: [REDACTED]

Emergency Contact 2: Name: [REDACTED] Relationship: Son Phone: [REDACTED]

Footer: "This Information is for your safety and the safety of others"

Names mentioned: - Leida Hernandez — Employee of LSJE, LLC; position: Housekeeping; marital status: Married - Coorbin — Physician listed as doctor on emergency contact form (listed twice)