01.14.06: Medical information disclosure

By signing below, I agree to the following statement:

I give EMM permission to share my medical form ­including medical insurance, medical 
history, and emergency contact information – as well my medical directive (including but 
not limited to living will and healthcare power of attorney instructions) with my 
immediate supervisor on the field.
 ___________________________ Name (please print) 

___________________________ Signature

_____________________ Date

Nita Landis,
Sep 28, 2016, 11:55 AM