Emergency Contact Form (Page 2 of 2) in pdf

Emergency Contact Form Page 2

Are you taking any medication we should be aware of? Yes / No _____________

If yes: Please list all medications we should be aware of:

Do you have any medical/mobility/mental health concerns of which we should be aware? Yes / No _____________

If yes, please list medical/mobility/mental health concerns that we should be aware of: ____________________________

_________________________________________________________________________________________________

The information requested on this card is confidential and for emergency use only. In the event of a medical emergency, this

information will be used by authorized emergency personnel. Please be honest when completing all pertinent information.

In the case of emergency, I give permission for my information to be released to emergency personnel. I also agree that any

of my emergency contacts listed on this card may be notified in an emergency, as needed.

Signature & Date: _______________________________________ Name: _______________________________

Emergency Contact Form Page 2