Emergency Contact Form
This information will only be used in case of medical emergency or arrest, and will be deleted immediately following the event. Please fill out as much or as little as you like, but do please include an emergency contact.
PLEASE WRITE THE NATIONAL LAWYERS' GUILD HOTLINE ON YOUR BODY (212)679-6018.
What is your name? (first and last)
If your name appears differently on your ID, what name is used on your ID? (first and last)
This is in case you're arrested or hospitalized, and we need to locate you.
What are your preferred gender pronouns?
What is your address?
What is your phone number?
What is your date of birth?
What is the name of your emergency contact? (The person we will call in case of arrest or medical emergency)
What is your emergency contact's phone number?
What is your emergency contact's relationship to you?
Are you allergic to any medication?
Any special instructions / conditions / info for EMS or paramedics?
In case of arrest, what is your cell preference according to gender? (i.e. "women's," "men's," "single cell, etc.)
Send me a copy of my responses.
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service