Emergency Contact Form
All information provided will be kept confidential, and destroyed after the action. This information will only be used in case of medical emergency or arrest.
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) *
What pronouns do you use? (He/him, She/her, They/them)
What is your address?
What is your phone number?
What is your date of birth? *
MM
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DD
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YYYY
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.)
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