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Logan and Beaudesert Bushwalkers Inc.
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This information is for emergency use only. Carried in your pack in a waterproof bag labelled EMERGENCY INFORMATION. Ensure this is easily accessible
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Name:Marija Zuvela
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Home Address:Unit 35, 122 Johnson Road Hillcrest
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Email:maravelaluka@gmail.com
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Mobile :0413 270 430Car Rego:829OX9
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Medical Information - Medical Condition/s:
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Thyrodectomy
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Medications in Pack? Yes / No
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Blood GroupO+Allergiesnone
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Do you have current immunisation against: Tetanus Yes / No Hep A Yes / No Hep B Yes / No
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Doctors Details:
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NameDr Deniece ChapmanPhone No.33800111
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Address / Medical Centre:
2/10 Grand Plaza Dr, Browns Plains
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Medicare Number : 4450 075613 3
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Private Health Insurance Fund (name):
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Membership No.
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Next of Kin -Name:Rhea BasicRelationship:Daughter
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Home Address:
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Contact Number:0437 553 074
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Your signature:Date:
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Privacy Statement: The information contained in this form is for emergency use only and will be accessed if you are ill or injured while participating in an activity of the club.
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Version 2. 6/2/19
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