Emergency Contact

Goodwill Industries of Wayne and Holmes Counties, Inc.

Emergency Contact Persons and Telephone Numbers
Date*

MonthDayYear
Date
Name of Consumer*
Consumer Phone Number*
Emergency Notification Name*
Emergency Notification Phone Number*
Emergency Notification Name
Emergency Notification Phone Number
Child Care Provide Phone Number
Select the method that was used to complete form*
Case Manager Name*
Title*
Date*

MonthDayYear
Date
Should be Empty: