2020 Company: Method of Payment, Emergency Contacts and Allergies

2020 Company—Method of Payment, Emergency Contacts and Allergies

First Name *

Last Name *

Cell Phone *

Email *

Method of payment preference *

I would like to be paid via Direct Deposit. I have included a VOID cheque with my contract.

I would like to be paid via Direct Deposit. I will email Rhea at [email protected] with deposit details.

I would like to be paid via cheque.

Emergency Contact Name *

Emergency Contact Cell *

Emergency Contact Relationship *

Please list all allergies and indicate if they are life-threatening

Do you carry an Epi-pen?

Yes

Consent

I give my consent for Bard to share the above Allergy and Emergency contact information with key-personnel that might need to be informed.