Emergency Contact Form

EMERGENCY CONTACT FORM

When possible, emergency information will be broadcast to employee cell phones by e-mail and text message. In order for a text message to be sent, you must include your cell phone service provider below.
If you have e-mail capability on your cell phone and do not desire to receive emergency information by text message, do not include your cell phone service provider.

The additional contact information below may be needed in severe emergency situations where e-mail and/or cell phone service is disrupted or in the event you have a medical emergency at work.

The emergency notification system ensures that employees receive critical information for their safety and benefits as quickly as possible. Required information is indicated by an asterisk (*) on the form below. Employees assume personal responsibility for any information from the Mississippi Department of Education that is not received due to failure to provide the below contact information.

MDE Office *

Job Title *

Name *


First *		Last *

Home Address *

Home City / State / Zip *


City	State	Zip

Home Phone *

XXX-XXX-XXXX

Work Email *

Cell Phone / Carrier

XXX-XXX-XXXX		Cell Carrier
Cell Number

Personal Email

Person who will know how to contact you in emergency evacuation situations

Name

Relationship

Phone Number

XXX-XXX-XXXX

Whom do you wish to be notified if you have a medical emergency at work?

1. Name

Relationship

Phone Number

XXX-XXX-XXXX

2. Name

Relationship

Phone Number

XXX-XXX-XXXX

* Required Field

Mississippi Department of Education
359 North West Street
Jackson, MS 39201
601-359-1737