Employee Emergency Contact Form - Household Staff Member

EMERGENCY CONTACT FORM

Company: LSJE, LLC Address: 6100 Red Hook Quarters Suite B-3 St. Thomas, VI 00802

Form Date: 04/09/18 Start Date: [Not filled]

Employee Information: - Employee Name: [REDACTED] - Address: [REDACTED] St. Thomas, VI 00802 - Date of Birth: [REDACTED] - Phone: [REDACTED] - Cell: [REDACTED] - E-Mail: [Not filled] - Title/Position: Housekeeper - Marital Status: Married - License: [Not filled]

Health and Medical Information: - Allergies or Health Concerns: No - Blood Type: [REDACTED] - Current Medication: [Not filled] - Doctor's Name: [Not filled] - Doctor's Name: [Not filled] - Doctor's Phone(s): [Not filled]

Emergency Contacts: - Name: [REDACTED], Relationship: [Not filled], Phone: [REDACTED] - Name: [REDACTED], Relationship: Pastor, Phone: [REDACTED]

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

Names mentioned: - [Name redacted] — Employee - Housekeeper position at LSJE, LLC property in St. Thomas, Virgin Islands