Address Change Form & Other Information Updates

Address Change & Other Contact Information Updates

Use this form to make updates or changes to your contact information including address changes, phone number updates, and emergency contact information.

Name*

First Name

Last Name

Email*

Confirm Email *

Employment Type*

PLEASE NOTE: Student workers also have to change their address with Admissions & Records for student records. Click here to update your address with A&R. You can also email admissionshelp@elcamino.edu.

Department*

Social Security (last 4 digits) or ID Number*

Preferred Name*

First Name

Last Name

Gender*

Female Male Non-binary I choose not to self-identify

Pronoun Identifier

She/her/hers/herself He/him/his/himself They/them/their/themselves

Other:

Personal Contact Information Update

New Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Which phone number are you updating? (check all that apply)*

Home Phone # Cell Phone #

Other:

For "Other," please specify type of # and note phone # in the space provided.

Home Phone #*

Cell Phone #*

Are you represented by the AFT, ECCE, or POA union?*

Yes No

Do you want your updated phone number released to your union?*

Yes No

Emergency Contact (in case of accident or serious illness)

Name of Emergency Contact*

First Name

Last Name

Relationship

(Example: spouse, parent, sibling, neighbor, etc.)

Phone #*

Work Number (if different from primary phone #)

Address (if known)

Address Line 1

Address Line 2

City

State

ZIP Code

Would you like to add a secondary emergency contact in the event that the District is unable to reach your primary emergency contact? *

Yes No

Name of Emergency Contact #2*

First Name

Last Name

Relationship

(Example: spouse, parent, sibling, neighbor, etc.)

Phone # *

Work Number (if different from primary phone #)

Address (if known)

Address Line 1

Address Line 2

City

State

ZIP Code

Personal Physician's Contact Information

Physician's Name*

First Name

Last Name

Physician's Phone Number*

Hospital of Choice (if unable to reach physician)

Name of Hospital - include address, city, state, zip

Address Line 1

Address Line 2

City

State

ZIP Code

Hospital's Phone Number

Authorization Signature

Any additional information to add (optional)

Updates will become effective as soon as they are processed by Human Resources. This can take from 1 to 5 work days. If you would like updates/changes to take effect for a future date, please provide specific instructions in the text box above.

Signature*

[clear]

Use your mouse or finger to draw your signature above

HR USE ONLY

Date Processed*

Name of HR person processing update*

Check box if updated in these systems*

HRS Datatel MAR Form (for classified employees)