Emergency Medical Information Form
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1Emergency Medical Information Form
Pilgram Name: _______________________________________________________
________________________
Preferred Name:
Last
First
Middle
Address: __________________________________________________________________________________________________
Street
City
State
Zip
Home Phone: _____________________________________ Work Phone: ____________________________________________
If I have medical emergency during the weekend, please contact the individuals noted below in the order indicated:
1. _________________________________________________________________________________________________________
Name
Phone
Alternative Phone
Relationship
2. _________________________________________________________________________________________________________
Name
Phone
Alternative Phone
Relationship
3. _________________________________________________________________________________________________________
Name
Phone
Alternative Phone
Relationship
Doctor: ____________________________________________________________________________________________________
Name or Practive Name
Phone Number
After Hours Phone
Address: __________________________________________________________________________________________________
Street
City
State
Zip
I currently take the following prescription medications (include dosage):
_____________________________________________ for________________________ dosage ___________________________
Medication Name
_____________________________________________ for________________________ dosage ___________________________
Medication Name
_____________________________________________ for________________________ dosage ___________________________
Medication Name
_____________________________________________ for________________________ dosage ___________________________
Medication Name
I understand the above information will be held in confidence within the Tennessee Via de Cristo organization but
may be shared with emergency medical personnel in an emergency. It will be destroyed after the weekend retreat.
________________________________________________________________________
_____________________________
Pilgrim’s Signature:
Date:
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Parent category: Business