C Phon Today's Date: [10/21/18 Employee Name: Physical Address: Mailing Address: Cell Phone: Title/Position: E-mail: Peter St Omer Operator Allergies or Health Concerns: N/A LSJE, LLC 6100 Red Hook Quarters, Suite B-3, St. Thomas, VI 00802-1348 E-mail: thesaintjames.group@gmail.com Emergency Contact Form Blood type: A- El A+ E AB- El AB+ Current Medications: Doctor's Name: Doctor's Name: In case of emergency, please contact: Name: Name: Demitri Kishma Relationship: Relationship: Son Friend Start Date: Date of Birth Phone (other): Marital Status: Driver's License No: Married EJ B+ ❑ o- n o+ ri Unknown Doctor's Phone: Doctor's Phone: Phone: Phone: This information is for your safety and the safety of others. EFTA01304186