Rider Education Program Emergency Information Form
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1N.12 Emergency Information Form
GOLD WING ROAD RIDERS ASSOCIATION
RIDER EDUCATION PROGRAM
Emergency Information Form
[Do Not Remove Helmet Until I am Examined by a Doctor]
Date:_________
Name:
Home Phone:
Work Phone:
Address:
City:
State/Zip:
Date of Birth:
Sex:
Social Security #:
Drivers License #:
State:
Employer/Phone:
GWRRA Member #:
Home Chapter/State:
Chapter Contact [Name & Phone #:
Emergency Contact/Name:
Relationship:
Phone/Home:
Work:
Address:
City:
State/Zip:
Do Not leave an emergency message on an answering machine - contact must be made directly to a person
Health Insurance:
Vehicle Insurance:
Company:
Company:
City/state:
City/state:
Phone:
Phone:
Policy/Group #:
Policy/Group #:
Allergies To Medications:
Medications Now Being Used:
1.
1.
2.
2.
3.
3.
4.
4.
Blood Type:
Wear Contact Lenses:
Yes:
No:
Blood Pressure:
Wear Dentures:
Yes:
No:
Family Doctor:
Special Notes/Health Problems:
Name:
Address:
City/State/Zip:
Phone:
[attach office card if available]
Local Police Department:
Address/Phone:
Sign here to authorize emergency medical treatment by a [doctor, hospital, EMT] when direct authorization cannot
be given:
GWRRA Emergency Information Form
Version 4.08 April 2008
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