Emergency Contact Form
Please provide a contact in the event of an emergency
Your Name
*
First Name
Last Name
ER Contact Name
*
First Name
Last Name
ER Contact E-mail
*
example@example.com
ER Contact Phone Number
*
Please enter a valid phone number.
Please provide relationship of emergency contact to you.
blank
.
Signature
*
Back
Next
Please review and acknowledge the following questions
I understand and agree with the following.
*
No expectation of compensation for my internship
No expectation of employment upon completion of my internship
My internship is to gain knowledge and assist in completing my university course work
I am not currently employed by Johnson County Government
This internship is voluntary and I choose by freewill to complete my internship
I agree to follow all departmental policy while completing my internship
Date
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Signature
*
Submit
Should be Empty: