Club Cruceros Emergency Information Form
Some fields are required. Please include as much other information as possible.
The Basics
Your First Name
Your answer
Your Last Name
Your answer
Your Boat Name or La Paz Street Address
Your answer
Your Phone Number (Include Country Code)
Your answer
Your Email
Your answer
Emergency Contact
Emergency Contact's Name (First & Last)
Your answer
Contact's Relationship To You
Your answer
Contact's Phone (Include Country Code)
Your answer
Contact's Email
Your answer
General Medical Information
Where do you store documents (such as passport) on your boat or in your home
Your answer
Your Date of Birth
MM
/
DD
/
YYYY
Your Blood Type
List Any Allergies You Have
Your answer
List any Current Medical Conditions (Asthma, Seizures, Headaches)
Your answer
Medication You Take Regularly
Your answer
Do You Have a Living Will or Do Not Resuscitate Order?
If So Where Is It Located?
Your answer
Doctors & Insurance Contacts
Name of Your Primary Doctor
Your answer
Doctor's Phone (Include Country Code)
Your answer
Doctor's E-mail
Your answer
Do You Have Medical Insurance? (For Example VA, Seguro Popular, Medicare, etc)
Insurance Provider
Your answer
Insurance Policy Number
Your answer
Insurance Company Phone (Include Country Code)
Your answer
Insurance Company Email
Your answer
Evacuation Insurance Provider
Your answer
Evac Ins Policy Number
Your answer
Evac Ins Phone (Include Country Code)
Your answer
Evac Ins Email
Your answer
Comments or Additional Information
Your answer
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