The New Bethel Church Membership Emergency Contact Information
This form is to provide assistance if you have a medical emergency while at the New Bethel Church or participating in a ministry event. You are not obligated to complete this form. The information you give is only to aid you & your family if you incur an emergency. Should you have any questions, please contact the church office at (913) 281-2002 or email info@newbethelkc.org
What is today's date? *
MM
/
DD
/
YYYY
Full Name *
Your answer
Home Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
In the event of an emergency, who should we contact on your behalf? *
Your answer
What is his/her relationship to you?
Your answer
What is the phone number of your emergency contact? *
Your answer
Do you have a primary physician? *
What is the name of your primary physician?
Your answer
What is the a contact phone number of your primary physician?
Your answer
Do you have any ongoing medical issues? *
Please explain (if any) any ongoing medical issues.
Your answer
Please list any allergies.
Your answer
Do you have a preferred hospital of choice? *
What is your hospital of choice?
Your answer
Do you have medical insurance? *
What is the name of your current medical insurance provider?
Your answer
Do you have burial insurance? *
What is the name of your current burial insurance provider?
Your answer
What additional information would you like us to know in case of an emergency?
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of New Bethel Church, Inc. Report Abuse - Terms of Service